HospitalInspections.org

The hospital must have a governing body which is effective in carrying out its responsibilities for the conduct of the hospital.

This CONDITION is not met as evidenced by:

Based on a review of facility documents, medical records (MR), observation and staff interviews (EMP), it was determined that the governing body failed to protect and promote each patient's rights (A0115) by failing to ensure patients; are informed of their rights (A0117, A0118, A0133, and A0145), receive care in a safe setting (A0144), and to have the use of restraints with modification of the care plan (A0166) and never as a PRN order (A0169).


Warren General Hospital has previously been out of compliance with State Deficiencies related to restraint usage as enumerated below.

A full State Licensure survey (B82G11) conducted September 18-21, 2012.

103.4(3) Functions: Take all reasonable steps to conform to all applicable Federal, State, and local laws and regulations.

Conditions of Participation for Patient's Rights 482.13;
482.13(e)(1)(ii)
482.13(e)(5)
482.13(e)(6)
482.13(e)(8)(iii)

An unannounced onsite complaint investigation (JAC11C060A) completed on June 21, 2011.

103.4(3) Functions: Take all reasonable steps to conform to all applicable Federal, State, and local laws and regulations.

Conditions of Participation for Patient's Rights 482.13;
482.13(a)(2)

A full State Licensure survey (LPNM11) conducted October 4-7, 2010.

103.4(3) Functions: Take all reasonable steps to conform to all applicable Federal, State, and local laws and regulations.

Conditions of Participation for Patient's Rights 482.13;
482.13(e)
482.13(e)(4)(i)
482.13(e)(5)
482.13(e)(6)
482.13(e)(10)
482.13(e)(11)
482.13(e)(12)
482.13(e)(12)(ii)A-D
482.13(f)
482.13(f)(1)
482.13(f)(2)
482.13(f)(2)(ii)
482.13(f)(2)(iii)
482.13(f)(2)(v)
482.13(f)(4)

A Special Monitoring visit (LOYC11) conducted on January 27, 2010.

103.4(3) Functions: Take all reasonable steps to conform to all applicable Federal, State, and local laws and regulations.

Conditions of Participation for Patient's Rights 482.13;
482.13(a)(2)
482.13(e)(3)
482.13(e)(4)
482.13(e)(9)
482.13(e)(12)(ii) A-D

Findings include:

Review of the Warren General Hospital Patient Care Manual Policy Number 101.03, "Patients' Rights," effective May 1, 2012, revealed, "Warren General Hospital will provide healthcare services with an overriding concern for our patients' rights and dignity. State and federal laws guarantee certain rights to patients and their representatives, which are set forth the attached Statement of Patients' Rights. The Statement of Patients' Rights is prominently displayed in all registration areas of the hospital and on the hospital website. In addition, the hospital provides the Statement of Patients' Rights to all inpatients and observation patients (or their representative) upon admittance, or as soon as possible thereafter. The hospital will maintain documentation of receipt of the Statement of Patients' Rights in the patient's medical record."

1. Review of medical records failed to reveal patients or patient representatives were consistently informed of the rights in advance of discontinuing patient care. Review of MR6 and MR8 failed to reveal signed copies of the Important Message from Medicare (IMM) provided to the patients prior to discharge.

2. Observations revealed the facility failed to inform patients how to file a complaint. On June 21, 2013, at 10:45 AM it was observed there was no phone number and no address for lodging a grievance with the Pennsylvania Department of Health and no information that such action could be taken directly without using the hospital grievance process. Interview on June 21, 2013, at 10:55 AM with EMP33 confirmed the missing information.

3. Review of the November 2012, "Statement of the Patient's Rights & Responsibilities" information on June 19, 2013, failed to reveal that the patient has the right to: 1) Have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital; 2) Receive care in a safe setting; 3) Be free of all forms of abuse or harassment. Interview on June 19, 2013, at approximately 11:45 AM with EMP2, confirmed the missing information, that the information was the same that was provided to patients, and revealed, "I thought it was in there."

4. Review of facility documents, observations, and interviews revealed the facility failed to protect and promote each patient's rights. Review of the patient complaint/grievance log for March 2013, revealed MR4 had laid in his/her own vomit and urine for an extended period of time. During the facility investigation it was found the call bells were not loud enough to be heard by staff. The facility had the call bell system checked by maintenance and it was found that the call bells could not be made to sound any louder. Interview on June 19, 2013, at approximately 8:35 AM with EMP4 revealed, "It [capital budget] probably won't be approved for a couple months... They're [third floor nursing unit] still using the call bell system they have..." Observations on Unit 3B on June 20, 2013, at 11:40 AM revealed that call bells could not be heard while in the West hallway. Interview on June 20, 2013, at approximately 11:40 AM, with EMP5 revealed, "There is also no differentiation of sounds between a bathroom call bell light and a code alarm when pulled." Demonstration at that time revealed that there is no difference in the sounds. During the demonstration of call bell audibility, it was noted by the surveyors that when proceeding down the West extension hallway, call bells alarming in the 3B [Brokenstraw] hallway could not be heard. Call bells alarming in the 3A [Allegheny] hallway also could not be heard. It was further noted that the call bell directional lights, which indicate at the hallway intersections which hallway call bells are alarming in, were not functional.

5. Review of medical records revealed that patients were placed in restraints without a current physician order. Review of MR8 on June 19, 2013, at approximately 9:30 AM revealed the patient was ordered soft wrist restraints. Documentation by nursing staff indicated that the patient was restrained with soft wrist restraints and mitts from April 28, 2013 at 5:00 AM until May 4, 2013 at 12:30 PM without the order being renewed as directed by facility policy every 24 hours. Interview on June 21, 2013, at 11:55 AM confirmed that mitts were considered restraints, it was not included in the physician order, and there were no additional orders after the initial order for the soft wrist restraints.

6. Review of medical records revealed restraints were ordered on a PRN, as needed, basis. Review of MR10 on June 19, 2013, at approximately 1:00 PM revealed an order to escalate to 4-point restraints if needed. Additional review of MR26 on June 19, 2013, at approximately 1:15 PM revealed a physician order for "mitts" PRN.

7. Review of medical records revealed the patient's right to proper assessment and pain control was not provided. Review of MR6 on June 19, 2013, at approximately 10:30 AM revealed the patient was provided a Morphine pain control device on April 20, 2013. The next nursing note was two and a half hours later. Review of MR7 on June 19, 2013, at 1:45 PM revealed the patient was medicated with a narcotic on April 10, 2013 at midnight. There was no additional pain assessment for two and a half hours. Per facility policy the pain was to be reassessed within 30 minutes.

Cross reference with:

482.13 Condition of Participation: Patient's Rights
482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible.
482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.
482.13(b)(4) - The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.
482.13(c)(2) - The patient has the right to receive care in a safe setting.
482.13(c)(3) - The patient has the right to be free from all forms of abuse or harassment.
482.13(e)(4) - The use of restraint or seclusion must be --
(i) in accordance with a written modification to the patient's plan of care.
482.13(e)(6) - Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN).

Based on review of facility documents and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure that the bylaws of the medical staff were enforced for four of five medical records (MR26, MR28, MR29, and MR30).

Findings include:

Review of the "Warren General Hospital Medical Staff Rules and Regulations and Allied Health Professional Rules and Regulations," updated February 27, 2013, revealed, "... Medical Staff Policies ... I. Orders and Notes. ... 2. Inpatient Orders Medication or treatment shall be administered to inpatients only upon written and signed orders (or an appropriate verbal order) of a practitioner acting within the scope of his or her license. All orders shall be signed, dated, and timed by the ordering practitioner. ..."

Review of Policy #104.02, "Inpatient Orders," effective April 1, 2011, revealed, "Medication or treatment shall be administered to inpatients only upon written and signed orders (or an appropriate verbal order) of a practitioner acting within the scope of his or her license. All orders shall be signed, dated, and timed by the ordering practitioner."

Review of policy, "Methicillin Resistant Staph Aureus (MRSA) Monitoring Policy," revised October 2008, no policy number provided, revealed, "... Procedure: ... 2. Nasal swabs will be conducted on all nursing home patients and high-risk patients admitted to Warren General Hospital, unless there is a positive history of a MDRO. ... 4. Nursing home and high risk patient to be nasal swabbed include but are not limited to those coming from: a. [OTH1] b. [OTH2] c. [OTH3] d. [OTH4] e. [OTH5] f. [OTH6] g. [OTH7] h. [OTH8] i. [OTH9] j. [OTH10] k. [OTH11] l. [OTH12] 5. Order for nasal swab will be included in the admission orders. ..."

Review of Policy #102.11, "Methicillin Resistant Staphylococcus Aureus (MRSA) Screening," dated February 12, 2008, revealed, "Nursing staff will document nasal culture for MRSA in the following manner: "Nasal Culture for MRSA per facility policy 102.11". ..."

1. Review of MR26, at approximately 1:15 PM on June 19, 2013, revealed that the patient was admitted from [OTH9].

Review of MR26 did not reveal a physician order for a MRSA nasal swab.

Review of MR26 revealed that a MRSA nasal swab was collected from the patient on March 27, 2013, at an unknown time; and received by the microbiology department at 7:18 PM on March 27, 2013.

At approximately 1:43 PM on June 19, 2013, EMP2 confirmed the above, that there was no order for a MRSA nasal swab.

At approximately 9:06 AM on June 20, 2013, when asked about an order for a MRSA nasal swab for MR26, EMP10 stated, "Part of the policy states that the doctor should be ordering it [MRSA nasal swab]. ... I'm not sure why it wasn't written. ... Nursing should have written it [MRSA nasal swab] on the order sheet. ... It [MRSA nasal swab] got done, but it wasn't written [order]."

At approximately 2:20 PM on June 20, 2013, upon request, EMP43, provided the surveyor with the names of the last four patients having MRSA nasal swabs in the last ten days (since June 10, 2013) (MR28, MR29, MR30, and MR31).

At approximately 3:45 PM on June 20, 2013, the surveyor requested that EMP2 verify if MR28, MR29, MR30, and MR31 had documentation of a physician order and/or nursing documentation per facility policy for MRSA nasal swab.

2. Focused review of MR28, on June 20, 2013, at approximately 2:40 PM, revealed that the patient had a MRSA nasal swab collected on June 10, 2013, at 7:25 PM.

3. Focused review of MR29, on June 20, 2013, at approximately 2:45 PM, revealed that the patient had a MRSA nasal swab collected on June 11, 2013, at 8:39 PM.

4. Focused review of MR30, on June 20, 2013, at approximately 2:50 PM, revealed that the patient had a MRSA nasal swab collected on June 12, 2013, at 4:00 PM.

At approximately 9:30 AM on June 21, 2013, EMP2 confirmed that the records [MR28, MR29, and MR30] do not contain the statement by nursing and/or the physician order required, per policy, for MRSA nasal swab.

Warren General Hospital failed to protect and promote each patient's rights.

This CONDITION is not met as evidenced by:

Based on a review of facility documents, medical records (MR), observation and staff interviews (EMP), it was determined that the governing body failed to protect and promote each patient's rights (A0115) by failing to ensure patients; are informed of their rights (A0117, A0118, A0133, and A0145), receive care in a safe setting (A0144), and to have the use of restraints with modification of the care plan (A0166) and never as a PRN order (A0169).

Findings include:

Review of the Warren General Hospital Patient Care Manual Policy Number 101.03, "Patients' Rights," effective May 1, 2012, revealed, "Warren General Hospital will provide healthcare services with an overriding concern for our patients' rights and dignity. State and federal laws guarantee certain rights to patients and their representatives, which are set forth the attached Statement of Patients' Rights. The Statement of Patients' Rights is prominently displayed in all registration areas of the hospital and on the hospital website. In addition, the hospital provides the Statement of Patients' Rights to all inpatients and observation patients (or their representative) upon admittance, or as soon as possible thereafter. The hospital will maintain documentation of receipt of the Statement of Patients' Rights in the patient's medical record."

1. Review of medical records failed to reveal patients or patient representatives were consistently informed of the rights in advance of discontinuing patient care. Review of MR6 and MR8 failed to reveal signed copies of the Important Message from Medicare (IMM) provided to the patients prior to discharge.

2. Observations revealed the facility failed to inform patients how to file a complaint. On June 21, 2013, at 10:45 AM it was observed there was no phone number and no address for lodging a grievance with the Pennsylvania Department of Health and no information that such action could be taken directly without using the hospital grievance process. Interview on June 21, 2013, at 10:55 AM with EMP33 confirmed the missing information.

3. Review of the November 2012, "Statement of the Patient's Rights & Responsibilities" information on June 19, 2013, failed to reveal that the patient has the right to: 1) Have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital; 2) Receive care in a safe setting; 3) Be free of all forms of abuse or harassment. Interview on June 19, 2013, at approximately 11:45 AM with EMP2, confirmed the missing information, that the information was the same that was provided to patients, and revealed, "I thought it was in there."

4. Review of facility documents, observations, and interviews revealed the facility failed to protect and promote each patient's rights. Review of the patient complaint/grievance log for March 2013, revealed MR4 had laid in his/her own vomit and urine for an extended period of time. During the facility investigation it was found the call bells were not loud enough to be heard by staff. The facility had the call bell system checked by maintenance and it was found that the call bells could not be made to sound any louder. Interview on June 19, 2013, at approximately 8:35 AM with EMP4 revealed, "It [capital budget] probably won't be approved for a couple months... They're [third floor nursing unit] still using the call bell system they have..." Observations on Unit 3B on June 20, 2013, at 11:40 AM revealed that call bells were not able to be heard while in the West hallway. Interview on June 20, 2013, at approximately 11:40 AM, with EMP5 revealed, "There is also no differentiation of sounds between a bathroom call bell light and a code alarm when pulled." Demonstration at that time revealed that there is no difference in the sounds. During the demonstration of call bell audibility, it was noted by the surveyors that when proceeding down the West extension hallway, call bells alarming in the 3 B [Brokenstraw] hallway were not able to be heard. Call bells alarming in the 3A [Allegheny] hallway were also unable to be heard. It was further noted that the call bell directional lights, which indicate at the hallway intersections which hallway call bells are alarming in, were not functional.

5. Review of medical records revealed that patients were placed in restraints without a current physician order. Review of MR8 on June 19, 2013, at approximately 9:30 AM revealed the patient was ordered soft wrist restraints. Documentation by nursing staff indicated that the patient was restrained with soft wrist restraints and mitts from April 28, 2013 at 5:00 AM until May 4, 2013 at 12:30 PM without the order being renewed as directed by facility policy every 24 hours. Interview on June 21, 2013, at 11:55 AM confirmed that mitts were considered restraints, it was not included in the physician order, and there were no additional orders after the initial order for the soft wrist restraints.

6. Review of medical records revealed restraints were ordered on a PRN, as needed, basis. Review of MR10 on June 19, 2013, at approximately 1:00 PM revealed an order to escalate to 4-point restraints if needed. Additional review of MR26 on June 19, 2013, at approximately 1:15 PM revealed a physician order for "mitts" PRN.

7. Review of medical records revealed the patient's right to proper assessment and pain control was not provided. Review of MR6 on June 19, 2013, at approximately 10:30 AM revealed the patient was provided a Morphine pain control device on April 20, 2013. The next nursing note was two and a half hours later. Review of MR7 on June 19, 2013, at 1:45 PM revealed the patient was medicated with a narcotic on April 10, 2013 at midnight. There was no additional pain assessment for two and a half hours. Per facility policy the pain was to be reassessed within 30 minutes.

Cross Reference with:

482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible.
482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.
482.13(b)(4) - The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.
482.13(c)(2) - The patient has the right to receive care in a safe setting.
482.13(c)(3) - The patient has the right to be free from all forms of abuse or harassment.
482.13(e)(4) - The use of restraint or seclusion must be --
(i) in accordance with a written modification to the patient's plan of care.
482.13(e)(6) - Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN).

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to include all of the patient rights in the information provided to patients when admitted to the facility and failed to ensure that the "Important Message from Medicare" (IMM) was issued within 2 days of admission and another copy was issued timely prior to discharge for patients that were discharged more than 2 days after the initial notice was provided in two of four medical records (MR6 and MR8).

Findings include:

Review of the Warren General Hospital Patient Care Manual Policy Number 101.03, "Patients' Rights," effective May 1, 2012, revealed, "Warren General Hospital will provide healthcare services with an overriding concern for our patients' rights and dignity. State and federal laws guarantee certain rights to patients and their representatives, which are set forth the attached Statement of Patients' Rights. The Statement of Patients' Rights is prominently displayed in all registration areas of the hospital and on the hospital website. In addition, the hospital provides the Statement of Patients' Rights to all inpatients and observation patients (or their representative) upon admittance, or as soon as possible thereafter. The hospital will maintain documentation of receipt of the Statement of Patients' Rights in the patient's medical record."

Review of Patient Care Policy 101.17 Appendix A "Patient Rights" no date provided revealed, "Procedure for Delivery of "Important Message From Medicare" Note: This procedure applies to hospital inpatients with Medicare insurance as either primary or secondary payer. This does not apply to ER patients, outpatients, or observation (RTS) patients. 1. Initial Notice at Admission a. Inpatient admission of a Medicare beneficiary i. During the registration process, the registrar will give the patient the Important Message From Medicare... Photocopy the signed and dated Important Message. Give the original to the patient and place the copy on the chart... 2. Follow-up Notice a. The beneficiary must receive follow-up notice prior to discharge, but not more than 2 days prior to discharge... e. Transfers to a different level of care: Follow-up notice must be given when a patient is transferred to a different level of care (ex. hospital care to skilled nursing care or to the transitional care unit).

1. Review of the November 2012, "Statement of the Patient's Rights & Responsibilities" information on June 19, 2013, revealed the facility failed to include the following rights: 1. The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital, 2. The patient has the right to receive care in a safe setting, and 3. The patient has the right to be free from all forms of abuse or harassment.

2. Interview on June 19, 2013, at approximately 11:45 AM with EMP2, confirmed the missing information, that the information was the information provided to patients, and revealed, "I thought it was in there."

3. Review of MR6 on June 20, 2013, at 11:30 AM revealed a signed IMM form completed on admission, April 16, 2013. Further review of MR6 revealed no documentation that a signed copy of the IMM was presented to the patient prior to discharge on April 28, 2013.

4. Review of MR8 on June 19, 2013, at approximately 3:15 PM revealed the patient was admitted on April 25, 2013, and an Important Message from Medicare (IMM) form was signed during the admission process on that date. The patient was discharged on May 7, 2013. Both copies of the carbon copy form were found, presumably for the discharge, unsigned and undated in the medical record. Interview on June 20, 2013 at 11:40 AM with EMP2 when asked if he/she could find a signed copy of the form that was provided to the patient prior to discharge revealed, "I don't see one."

Cross reference with:
482.13(b)(4)
482.13(c)(2)
482.13(c)(3)

Based on review of facility documents, observation and staff interview (EMP), it was determined that the facility failed to ensure provision to each patient or patient's representative a phone number and address for lodging a grievance with the Pennsylvania Department of Health and to further include information that such action may be taken directly without using the hospital grievance process in the hospital based Warren Medical Group Practice.

Findings include:

Review of the Warren General Hospital Patient Care Manual Policy Number 101.03, "Patients' Rights," effective May 1, 2012, revealed, "The Statement of Patients' Rights is prominently displayed in all registration areas of the hospital and on the hospital website."

1. Tour of the Warren Medical Group Practice waiting room on June 21, 2013, at 10:45 AM reveled the Statement of Patients' Rights posted. Review of the posting and other posted notifications revealed no phone number and address for lodging a grievance with the Pennsylvania Department of Health or information that such action may be taken directly without using the hospital grievance process.

2. On June 21, 2013, at 10:55 AM, EMP33 confirmed that no phone number and address for lodging a grievance with the Pennsylvania Department of Health or information that such action may be taken directly without using the hospital grievance process was displayed in the room. EMP33 stated, "Right. It should be there. We will have to have that added."

Cross reference with:

482.13
482.13(a)(1)
482.13(b)(4)
482.13(c)(2)
482.13(c)(3)
482.13(e)(4)(i)
482.13(e)(6)

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure notification of patients of their right to have a family member or representative of his or her choice and his or her physician notified promptly of his or her admission to the hospital.

Findings include:

Review of the Warren General Hospital Patient Care Manual Policy Number 101.03, "Patients' Rights," effective May 1, 2012, revealed, "Warren General Hospital will provide healthcare services with an overriding concern for our patients' rights and dignity. State and federal laws guarantee certain rights to patients and their representatives, which are set forth the attached Statement of Patients' Rights. The Statement of Patients' Rights is prominently displayed in all registration areas of the hospital and on the hospital website. In addition, the hospital provides the Statement of Patients' Rights to all inpatients and observation patients (or their representative) upon admittance, or as soon as possible thereafter. The hospital will maintain documentation of receipt of the Statement of Patients' Rights in the patient's medical record."

1. Review of the November 2012, "Statement of the Patient's Rights & Responsibilities" information on June 19, 2013, failed to reveal that the patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.

2. Interview on June 19, 2013, at approximately 11:45 AM with EMP2, confirmed the missing information, that the information was what was provided to patients, and revealed, "I thought it was in there."


Cross reference with:
482.13
482.13(a)(1)

Based on review of facility documents, staff interviews (EMP), and observations, it was determined the facility failed to ensure inclusion in the Patient Rights that the patient has the right to receive care in a safe setting as part of the patient rights provided to patients when they are admitted to the facility, and failed to provide a safe setting for care in one of one medical records (MR4).

Findings include:

Review of the Warren General Hospital Patient Care Manual Policy Number 101.03, "Patients' Rights," effective May 1, 2012, revealed, "Warren General Hospital will provide healthcare services with an overriding concern for our patients' rights and dignity. State and federal laws guarantee certain rights to patients and their representatives, which are set forth the attached Statement of Patients' Rights. The Statement of Patients' Rights is prominently displayed in all registration areas of the hospital and on the hospital website. In addition, the hospital provides the Statement of Patients' Rights to all inpatients and observation patients (or their representative) upon admittance, or as soon as possible thereafter. The hospital will maintain documentation of receipt of the Statement of Patients' Rights in the patient's medical record."

1. Review of the November 2012, "Statement of the Patient's Rights & Responsibilities" information on June 19, 2013, failed to reveal that the patient has the right to receive care in a safe setting.

2. Interview on June 19, 2013, at approximately 11:45 AM with EMP2, confirmed the missing information, that the information was what was provided to patients, and revealed, "I thought it was in there."

3. Review of patient complaint/grievances for March 2013, revealed the patient of MR4 had laid in his own vomit and urine for an extended period of time. The facility's investigation in response to the complaint was that the call bells were not loud enough to be heard by staff.

4. Interview with EMP4 on June 19, 2013, at approximately 8:35 AM, revealed that an e-mail had been sent to the manager of Unit 3B (the nursing unit that MR4 had been on at the time of the incident). The e-mail noted that the call bells were as loud as they could be and a proposal would be presented during the capital budget meeting.

EMP4 further added, "It [capital budget] probably won't be approved for a couple months. ... They're [third floor nursing unit] still using the call bell system they have. ..."

5. Observations on Unit 3B on June 20, 2013, at 11:40 AM revealed that call bells could not be heard when in the West hallway.

Interview on June 20, 2013, at approximately 11:40 AM with EMP5 revealed, "... It's still kind of an issue, because our system is old. ... What you hear right now is as loud as it gets. ... When you are in a patient room, ... you can't hear it [call bell]."

6. During the demonstration of call bell audibility, it was noted by the surveyors that when proceeding down the West extension hallway, call bells alarming in the 3B [Brokenstraw] hallway could not be heard. Call bells alarming in the 3A [Allegheny] hallway also could not be heard.

7. It was further noted that the call bell directional lights, which indicate at the hallway intersections which hallway call bells are alarming in, were not functional.



Cross reference with:
482.13(a)(2)
482.13(c)(2)

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure inclusion in the Patient Rights that the patient has the right to be free from all forms of abuse or harassment in the information provided to patients when admitted to the facility.

Findings include:

Review of the Warren General Hospital Patient Care Manual Policy Number 101.03, "Patients' Rights," effective May 1, 2012, revealed, "Warren General Hospital will provide healthcare services with an overriding concern for our patients' rights and dignity. State and federal laws guarantee certain rights to patients and their representatives, which are set forth the attached Statement of Patients' Rights. The Statement of Patients' Rights is prominently displayed in all registration areas of the hospital and on the hospital website. In addition, the hospital provides the Statement of Patients' Rights to all inpatients and observation patients (or their representative) upon admittance, or as soon as possible thereafter. The hospital will maintain documentation of receipt of the Statement of Patients' Rights in the patient's medical record."

1. Review of the November 2012, "Statement of the Patient's Rights & Responsibilities" information on June 19, 2013, failed to reveal documentation that the patient has the right to be free from all forms of abuse or harassment.

2. Interview on June 19, 2013, at approximately 11:45 AM with EMP2, confirmed the missing information, that the information was the same that was provided to patients, and revealed, "I thought it was in there."

Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure that the use of a restraint or seclusion was in accordance with a written modification to the patient's plan of care for two of four medical records (MR8 and MR10).

Findings include:

Review of the Nursing Services policy #2271A, "Restraints, Medical" revised in 2007, effective January 3, 2011, revealed, "Definition of Restraint: A restraint can be imposed by physical means ... A physical restraint includes any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the patient's body that is unable to be easily removed that restricts freedom of movement or normal access to one's body... Procedure: 1. An order from the Physician or Licensed Independent Practitioner (LIP) is required before a restraint may be used (except in emergency circumstances, in which case the order must be obtained as soon as possible after the application of the restraint)... 6. The maximum duration of the order is 24 hours. If the need for restraint exists after the expiration of the order, a Physician or LIP must re-order the restraint... the RN will attempt and document 'alternatives to the restraint'. The RN or LPN will initiation [sic] the Care Plan addressing the behavior and interventions individualized for the patient..."

1. Review of MR8 on June 19, 2013, at approximately 9:30 AM revealed a physician order on April 28, 2013, at 5:00 AM for soft wrist restraints (for medical purposes). Documentation in the medical record revealed the patient had wrist restraints and mitts in place from April 28, 2013, until May 4, 2013, at 12:30 PM. No additional orders to continue the wrist restraint were found nor was there an order for the mitts. There were no changes to the care plan to reflect the absence of additional orders to continue restraints. Interview with EMP2 on June 19, 2013, at 11:45 AM confirmed there were no orders to continue the restraints. Interview with EMP2 on June 21, 2013, at 11:55 AM confirmed that the mitts would be considered a restraint, which was not included in the order but were in the plan of care.

2. Review of MR10 on June 19, 2013, at approximately 1:00 PM revealed an order on June 15, 2013, at 12:35 PM for the patient to have "soft wrist restraints" applied (for behavioral purposes). Documentation at 1:00 PM revealed the city police were called to assist with placement of soft wrist restraints. Documentation at 2:20 PM revealed the patient was in bilateral soft wrist restraint. A miscellaneous order on June 15, 2013, at 3:54 PM revealed, "Restrain for 24 h [hours], assaultive [sic] behavior & suicidal behavior with attempt; escalate to 4 pt leather if needed." The shift assessment for 3:45 PM revealed, "soft wrist restraints on both hands and on left foot. mitts placed on both hands..." The shift summary noted the physician was called and updated on all assessments. "patient at 1745 [5:45 PM] put into 4 point restraints ..." Interview on June 20, 2013, at 3:35 PM with EMP2 confirmed the orders (used to initiate the care plan) were not written according to hospital policy and that there were no orders for the mitts.

Cross reference with :
482.13(e)(6)

Based on review of facility documents and medical records (MR), personnel files (PF), and employee interviews (EMP), it was determined that the facility failed to ensure that orders for the use of restraint must never be written on an as needed basis (PRN) for two of four medical records (MR10 and MR26).

Findings include:

Review of Policy #2271A, "Restraints, Medical," effective January 3, 2011, revealed, "Procedure: ... 2. Restraints may not be ordered as a standing order or on an "as needed" or PRN basis. ..."

1. Review of MR26, at approximately 1:15 PM on June 19, 2013, revealed, "Doctor's Orders ... 3/27/13 1525 Mitts prn ... Read back po [phone order]: ... [EMP36]. ..."

Review of MR26 revealed that the patient was in mitt restraints from March 27, 2013, at 4:00 PM until March 28, 2013, at 3:00 PM.

At approximately 1:43 PM on June 19, 2013, EMP2 confirmed that the, "Mitts prn," order was not written consistent with the facility policy (#2271A).

2. At approximately 2:45 PM on June 19, 2013, when presented with the, "Mitts prn," order, EMP36 stated, "Right. I know we aren't supposed to write it [restraint order] that way [prn]. That is the way it [restraint order] was given to me." When asked why EMP36 did not clarify the order, EMP36 stated, "I don't remember why it [restraint order] wasn't clarified."

Review of PF12 [EMP36] revealed education documentation from January 31, 2012, which stated, "Use of Restraint... 2. Policy and procedure will be reviewed ..." Further review of the documentation revealed the employee's signature, indicating that the policy and procedure were reviewed.

3. Review of MR10 on June 19, 2013, at approximately 1:00 PM, revealed an order on June 15, 2013, at 12:35 PM, for the patient to have "soft wrist restraints" applied. Documentation at 1:00 PM revealed the city police were called to assist with placement of soft wrist restraints. Documentation at 2:20 PM revealed the patient was in bilateral soft wrist restraints. A miscellaneous order on June 15, 2013, at 3:54 PM, revealed, "Restrain for 24 h, assaultive [sic] behavior & suicidal behavior with attempt; escalate to 4 pt leather if needed." The shift assessment for 3:45 PM revealed, "soft wrist restraints on both hands and on left foot. mitts placed on both hands..." The shift summary noted the physician was called and updated on all assessments. "patient at 1745 [5:45 PM] put into 4 point restraints ..." Interview on June 19, 2013, at approximately 2:45 PM, with EMP12 confirmed the order for leather restraints was the equivalent of a PRN order.

Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined that the facility failed to develop and keep current a nursing care plan for each patient in one of two records reviewed. (MR6)

Findings Include:

On June 19, 2013, at 1:30 PM, review of the facility's policy, #2015-AP, "Care Plan Policy," revealed, " ... Procedure: ... The 'Plan of Care' shall be individualized, based on the diagnosis, patient assessment and personal goals of the patient and his or her family.

1. On June 19, 2013, at approximately 11:30 AM, MR6 was reviewed. MR6 revealed that the patient had abdominal surgery with a new ileostomy, as well as a Patient Controlled Analgesia (PCA) pump. Continued review revealed that the patient's care plan did not document an individualized assessment and goals based on recent abdominal surgery and pain control.

2. On June 19, 2013, at 2:00 PM, EMP2 confirmed that the Plan of Care was not individualized for this Patient [MR6].

Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that pain reassessments were done per the facility's policy in two of two medical records reviewed. (MR6, MR7)

Findings Include:

Review of the facility's, "Statement of the Patient's Rights and Responsibilities," dated November 2012, states, "You have the Right to ... A proper assessment and management of pain ..."

On June 19, 2013, at 1:30 PM review of policy #2017-AP, "Pain Assessment, Reassessment and Management," revised September 1, 2006, states, "The patient will undergo reassessment of pain at least once per shift and after every pain control mechanism employed by patient care providers. Pain control mechanisms include but are not limited to: ... Use of Patient Controlled Analgesia (PCA) ... Repositioning the patient ... Any patient care provider, from any department, that has implemented a pain control mechanism will re-assess the patient within one-half (1/2) hour to determine the amount of pain control achieved ... Reassessment: ... the patient's ability to sleep does not always mean that there is an absence of pain."

1. On June 19, 2013, at 10:30 AM review of MR6 revealed a nurse's note dated April 20, 2013, at 1330, "... PCA of Morphine hung ..." the next nurses note is 2.5 hours later at 1600, "reported adequate pain relief from PCA."

2. On June 19, 2013, at 1:45 PM review of MR7 revealed that the patient was medicated with Dilaudid on April 10, 2013, at 0000. Further review of the record revealed that there was no reassessment for 2.5 hours.

3. On June 19, 2013, at 2:00 PM EMP2 was asked if the nurses' notes followed the facility's policy [for pain reassessment]. EMP2 replied, "No, the nurses did not re-assess within a 1/2 hour."

Based on review of facility documents and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure that all patient medical record entries were complete, dated, timed, and authenticated for 12 of 13 medical records (MR6, MR16, MR17, MR18, MR20, MR21, MR22, MR23, MR24, MR25, MR26, and MR27).

Findings include:

Review of the Warren General Hospital Medical Staff Rules And Regulations & Allied Health Professional Rules And Regulations, updated February 27, 2013, revealed, "F. MEDICAL RECORDS. Form and Content of Record ... All medical record entries must be legible, complete, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided. A medical record entry is "authenticated" when the responsible practitioner signs, dates and times the medical record entry. Practitioners using preprinted orders must date, time, and sign each page of the preprinted orders. ... Reference: Patient Care Policy 105.04."

Review of Policy #105.04, "Form and Content of Record," dated April 1, 2011, revealed, "... All medical record entries must be legible, complete, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided. A medical record entry is "authenticated" when the responsible practitioner signs, dates, and times the medical record entry. ..."

Review of Policy #104.02, "Inpatient Orders," dated April 1, 2011, revealed, "... All orders shall be signed, dated, and timed by the ordering practitioner. ..."

Review of a form, which is completed by registration staff, titled, "Advance Directive Record," revealed columns for "Date," and "Signature."

1. Review of MR6 on June 19, 2013, at approximately 10:30 AM, revealed an "Anesthesia Consent" in which the anesthesiologist obtaining the consent did not date or time the signing of the consent.

At approximately 1:40 PM on June 19, 2013, EMP2 confirmed the above findings.

2. Review of MR16 revealed, "Doctors Standing Orders," dated March 6, 2013. Review of the order revealed no time of the entry.

Review of MR16 revealed a form titled, "Inpatient Recertification Form," dated March 6, 2013. Review of the form revealed no time of the entry.

Review of MR16 revealed, "Medical Evaluation Form," dated March 6, 2013. Review of the form revealed no time of the entry.

Review of MR16 revealed an order for, "Oxygen Therapy Protocol." The review revealed no date or time of the order.

Review of MR16 revealed an order for, "Telemetry Protocol." The review revealed no date or time of the order.

Review of MR16 revealed orders for, "Venous Thromboembolism Risk Assessment and Prophylaxis." The review revealed no date or time of the order.

Review of MR16 revealed a physician progress note dated March 9, 2013. Review of the note revealed no time of the entry.

Review of MR16 revealed verbal orders dated March 5, March 6 (three orders) and March 8, 2013. Review of the orders revealed physician signatures with no date or time.

3. Review of MR17 revealed an Emergency Department (ED) physician order sheet dated April 10, 2013. Review of the order revealed no time of the entry.

Review of MR17 revealed, "Patient Transfer and Certification," dated April 10, 2013. Review of the form revealed no time of the entry.

Review of MR17 revealed, "Physician Certification Statement for Non-Emergency Ambulance Transportation," dated April 10, 2013. Review of the form revealed no time of the entry.

Review of MR17 revealed an Emergency Department (ED) physical examination dated April 10, 2013. Review of the examination revealed no time of the entry.

On June 19 2013, at 1:35 PM, EMP27 confirmed the missing dates and times for MR16 and MR17 stating, "Yes. They (entries) are incomplete."

4. Review of MR18 revealed an ED order sheet and an ED physical examination, both dated June 19, 2013. Review of the order sheet and examination revealed no time of the entries.

On June 19, 2013, at 1:50 PM, EMP27 confirmed the ED order sheet and the examination (MR18) had no time documented.

5. Review of MR20 revealed physical therapy treatment flow sheets dated May 30, June 4, and June 6, 2013. Review of the entries revealed initials with no signature or time of the entries.

6. Review of MR21 revealed physical therapy treatment flow sheets dated June 13, 2013, June 17, 2013, and June 20, 2013. Review of the entries revealed initials with no signature or time of the entries.

7. Review of MR22 revealed physical therapy treatment flow sheets dated June 4, 2013, June 6, 2013, June 12, 2013, June 14, 2013, and June 16, 2013. Review of the entries revealed initials with no signature or time of the entries.

On June 20, 2013, at 11:25 AM, EMP29 confirmed there were no signatures or times for the physical therapy treatments documented on MR20, MR21 and MR22 stating, "We can have them add that (signatures and times)."

8. Review of MR23 revealed an order for, "Standing Oncology Chemotherapy Protocol." Review of the order revealed no date or time.

Review of MR23 revealed a physician signature for a consent to administer blood dated June 17, 2013. Review of the consent revealed no time for the physician signature.

On June 21, 2013, at 10:00 AM, EMP34 confirmed there was no time documented for the standing chemotherapy order or the consent for blood on MR23 stating, "There is no time (documented)."

9. Review of MR24, at approximately 8:30 AM on June 19, 2013, revealed a "Pink Sheet Order," dated March 21, 2013. Review revealed no time of the order.

Review of MR24 revealed, "Doctors Standing Order," dated March 21, 2013. Review revealed no time of the order.

Review of MR24 revealed, "Oxygen (O2) Therapy Protocol," dated March 21, 2013. Review revealed no time of the order.

Review of MR24 revealed three verbal orders written on March 14, 2013. Review revealed no times of the orders.

Review of MR24 revealed the, "Emergency Department Record," dated March 13, 2013. Review revealed no time of the documentation.

Review of the, "Advance Directive Record," on MR24, at approximately 8:30 AM on June 19, 2013, revealed a date of March 14, 2013, under, "... 2) Patient has not completed an advance directive." Further review revealed the same under, "... 5) Advance directive pamphlet and form given to patient in admission packet." Review of the signature columns for the two entries revealed two initials.

At approximately 1:35 PM on June 19, 2013, EMP2 confirmed the above findings, and further confirmed that the documentation under the signature columns were initials, not signatures.

10. Review of MR25, at approximately 10:00 AM on June 19, 2013, revealed a physician order written on March 18, 2013. Review revealed no documentation of the time of the order.

Review of MR25 revealed a physician order dated March 19, 2013, with no time of the order indicated.

Review of MR25 revealed, "Patient Controlled Analgesia (PCA) Protocol," with no date and/or time of the order.

Review of MR25 revealed the, "Emergency Department Record," dated March 17, 2013. Review revealed no time of the documentation.

Review of the, "Advance Directive Record," on MR25, at approximately 10:00 AM on June 19, 2013, revealed a date of March 17, 2013, under, "... 2) Patient has not completed an advance directive." Further review revealed the same under, "... 5) Advance directive pamphlet and form given to patient in admission packet." Review of the signature columns for the two entries revealed no signatures.

At approximately 1:40 PM on June 19, 2013, EMP2 confirmed the above findings.

11. Review of MR26, at approximately 1:15 PM on June 19, 2013, revealed, "Physician Progress Note," dated March 28, 2013. Review revealed no time of the note.

Review of MR26 revealed, "Oxygen (O2) Therapy Protocol," dated March 27, 2013. Review revealed no time of the order.

Review of MR26 revealed, "Venous Thromboembolism (VTE) Risk Assessment and Prophylaxis Physician Order Set," dated March 18, 2013. Review did not reveal a time of the documentation.

Review of MR26 revealed, "Parenteral Nutrition," dated March 29, 2013. Review revealed no time of the order.

Review of MR26 revealed the, "Emergency Department Record," dated March 27, 2013. Review revealed no time of the documentation.

Review of MR26 revealed two physician orders dated March 28, 2013. Review revealed no time of the orders.

Review of the, "Advance Directive Record," on MR26, at approximately 1:15 PM on June 19, 2013, revealed a date of March 27, 2013, under, "... 2) Patient has not completed an advance directive." Further review revealed the same under, "... 5) Advance directive pamphlet and form given to patient in admission packet." Review of the signature columns for the two entries revealed two initials.

At approximately 1:40 PM on June 19, 2013, EMP2 confirmed the above findings, and further confirmed that the documentation under the signature columns were initials, not signatures.

12. Review of MR27, at 8:45 AM on June 21, 2013, revealed a date of June 19, 2013, under, "... 2) Patient has not completed an advance directive." Further review revealed the same under, "... 5) Advance directive pamphlet and form given to patient in admission packet." Review of the signature columns for the two entries revealed two initials.



*Cross reference with ?482.24(c)(1)(i)

Based on review of facility documents and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure that verbal orders were dated, timed, and cosigned per facility policy for six of eleven medical records (MR8, MR14, MR16, MR24, MR26, and MR27).

Findings include:

Review of the "Warren General Hospital Medical Staff Rules and Regulations and Allied Health Professional Rules and Regulations," updated February 27, 2013, revealed, "... I. Orders and Notes. 1. Verbal Orders. ... Verbal orders must be signed by the practitioner within 24 hours. The person recording the verbal order shall sign, date, and time the verbal order. ..."

Review of Policy #104.01, "Verbal Orders," dated April 1, 2011, revealed, "... Verbal orders must be signed by the practitioner within 24 hours. The person recording the verbal order shall sign, date, and time the verbal order. ..."

1. Review of MR8 on June 19, 2013, at approximately 11:00 AM revealed an order for diet consistency that was dated April 26, 2013. There was no documentation of the time of the order and no cosignature of the physician. This was confirmed by EMP2 on June 19, 2013, at 11:40 AM.

2. Review of MR14 on June 21, 2013, at approximately 9:55 AM revealed one untimed verbal order on June 5, 2013, that was not cosigned by the physician; a verbal order on June 11, 2013, at 5:00 PM that was cosigned by the physician, but not dated or timed; three verbal orders on June 12, 2013, at 2:15 AM, 4:00 AM, and 6:00 PM, that were cosigned by the physician without a date or time of the cosignature; two verbal orders on June 13, 2013, at 2:05 AM and 10:35 AM, that were cosigned by the physician without a date or time of the cosignature; and one verbal order on June 17, 2013, that was cosigned by the physician without a date and time of the signature. Interview on June 21, 2013, at 9:45 AM with EMP22 confirmed the lack of dates and times.

3. Review of MR16 revealed verbal orders dated March 5, March 6 (three orders) and March 8, 2013. Review of the orders revealed physician signatures with no date or time.

On June 19 2013, at 1:35 PM EMP27 confirmed the missing dates and times for MR16 stating, "Yes. They (entries) are incomplete."

4. Review of MR24, at approximately 8:30 AM on June 19, 2013, revealed three verbal physician orders on March 14, 2013; and one verbal physician order on March 15, 2013, which were cosigned without documentation of the date and/or time of the counter signature.

Review of MR24 revealed three verbal orders written on March 14, 2013. Review revealed no times of the orders.

At approximately 1:35 PM on June 19, 2013, EMP2 confirmed the above findings.

5. Review of MR26, at approximately 1:15 PM on June 19, 2013, revealed a verbal physician order written on March 29, 2013, which was cosigned without documentation of the date and/or time of the counter signature.

At approximately 1:40 PM on June 19, 2013, EMP2 confirmed the above findings.

6. Review of MR27, on June 21, 2013, at 8:45 AM, revealed a verbal order written on June 19, 2013, at 11:00 AM, which had not been cosigned by the physician.


*Cross reference with ?482.24(c)(1)