HospitalInspections.org

Based upon a review of facility documents and interview (EMP), it was determined that the facility governing body failed to execute a valid contract for teleradiology services.


Findings include:


On January 22, 2025, a review of the facility "Teleradiology Services Agreement," executed October 1, 2022, was completed. " Recitals: A. System is a nonprofit healthcare system comprised of hospitals and other healthcare facilities in and around Western Pennsylvania, including DuBois Hospital, Clearfield Hospital, Elk Hospital, and Brookville Hospital ... "


On August 31, 2022, Amendment 1 was executed and added Penn Highlands Connellsville to the existing teleradiology agreement for the Penn Highlands Healthcare System. However, there was no existing amendment to the "Teleradiology Services Agreement" which covers the teleradiology services which are rendered by the contractor at Penn Highlands Mon Valley.


On January 22, 2025, EMP2 reviewed the contract and confirmed the above at 2:07 PM.

Based on review of facility documentation, medical record (MR), and staff interview (EMP), it was determined that the facility failed to provide care in a safe setting by failing to establish and maintain a reliable system for the timely transfer of images to the teleradiologist for one of one medical records (MR1).

Findings include:

Review of facility policy "Radiology Requests 1-5", effective date: 5/13/2024, revealed: " ... Procedure: Emergency Room requests are entered into the information system as STAT. ... All imaging studies will be requested by their priority set up by the hospital ... STAT (immediately) ... ".
Review of facility documentation revealed issues with delayed electronic transmission of imaging results were reported on the following dates and times: January 11, 2025, at 12:30 AM; January 11, 2025, at 9:00 PM; January 12, 2025 at 9:30 AM; January 13, 2025 at 2:30 AM; and January 13, 2025 at 7:10 AM.
Review of MR1 revealed a CT and CTA of the head were ordered on January 13, at 12:59 AM. Further review of MR1 revealed that the results of the CT and CTA images were dictated/read by the teleradiologist on January 14, 2025 at 6:20 AM (approximately five and a quarter hour after they were ordered).
Based on interview with EMP2 on January 21,2025, at approximately 10:30 AM, the delay in transmission of the images to the teleradiologist contributed to the delay in reading the images for MR1.
The above findings related to delayed transmissions of imaging results were confirmed with EMP2 on January 21, 2025, at approximately 10:30 AM, and with EMP11 on January 22, 2025, at 1:45 PM.
The above findings related to MR1 were confirmed with EMP6 on January 22, 2025, at approximately 10:50 AM.



Based upon observation and staff interview (EMP), it was determined that the facility failed to maintain a clean and safe setting.

Findings include:

On January 21, 2025, from approximately 12:15 PM to 12:45 PM, an accompanied tour of the first floor Emergency Department and patient rooms was completed. Tour observations revealed the following:

Upon arrival to the entrance to the Emergency Department, a ceiling tile was dislodged, and two other ceiling tiles were soiled. Visible debris was hanging from the ceiling tile in the corner near the door at the entrance.

One ceiling tile in the area above Security was soiled.

Thirty-three light fixtures in the hallway revealed visible debris and dead insects.

Rooms three, six, and seven showed visible grey and black debris buildup along the doorway threshold. The floor in room seven had visible areas of yellow staining throughout.

Countertops in rooms three and six showed the top layer of laminate worn through, revealing a more porous feeling bottom layer.

The above findings were confirmed by EMP2 and EMP6 on January 21, 2025, at 12:35 PM.

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to follow hospital policies and procedures by not activating a stroke alert on a patient who presented in the Emergency Department with stroke-like symptoms for one of ten medical records reviewed (MR1).


Findings include:


On January 21, 2025, a review of the facility policy Emergency Department Documentation of the Emergency Department Electronic Medical Record (EMR) revealed, "To ensure appropriate documentation of all pertinent information related to the patient's chief complaint and continuing throughout their course of treatment. ....E. The Emergency Department Registered Nurse or Health Care Professional will utilize the Emergency Department Patient Record for initial patient assessment, reassessment, intervention and continued care. F. The frequency of reassessment is based upon the patients' acuity, condition, history and nursing judgment: Timing of reassessments should reflect the patient's status at any given moment they are in the treatment area, remembering that a patient's priority/acuity can change."


On January 21, 2025, a review of facility policy "Handoff Communication for Stroke Patients", last reviewed September 2022, revealed the following: "... III. Frequency of NIHSS and Vital Signs: ... B. Non Tenecteplase (TNKase) patient [SIC] will have an NIHSS and vital signs performed as follows: (This includes extended stay or boarded patients in the E.D.) 1. Every 4 hours x 48 hours. 2. Daily. 3. Discharge 4. During hand off from one unit to the next. 5. During hand off from one facility to the next."

On January 21, 2025, a review of the facility's "Acute Stroke Workflow" revealed, "Patient presents with symptoms consistent with acute ischemic stroke within 24 hours of symptom onset, Stroke Alert is Initiated. ED-Stroke Alert Page, Inpatient-RRT Stroke Alert, Initiate ED/Acute Stroke Work UP. Bedside Assessment."

On January 22, 2025, at 11:20 AM, a review of MR1 revealed that the patient presented to the Emergency Department with complaints of a headache, as well as transient left hand numbness and tingling. The patient and family also reported recent nausea, vomiting, and mild photophobia, and confusion. Further review of MR1 revealed no evidence of a stroke alert being called for the patient. A nurses note on January 13, 2025, at 12:55 AM, read "seen by [Emergency Physician] stroke alert not advised".

The above findings were confirmed by EMP6 during employee interview on January 22, 2025, between 11:00 AM and 2:00PM.