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Based on a review of facility policy, medical records (MR), and staff interview (EMP), it was determined the facility failed to provide notice of patient rights for five of five medical records reviewed (MR18, MR19, MR20, MR21 and MR22).

Findings include:

Review of facility policy and procedure, "Patient Rights and Responsibilities," last reviewed January 2019, revealed, "... Patient Rights' Overview ... Allegheny General Hospital wants patients, and their family members or guardians, to know their rights under federal and Pennsylvania state law as soon as possible during a hospital stay. ..."

Review of MR18, MR29, MR20, MR21, and MR22 revealed no documentation patients were informed of their rights and responsibilities.

Interview with EMP1 on May 16, 2019 at 10:46 AM confirmed the above findings.

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined the facility failed to follow their policy and procedure to transfer patients for three of three medical records reviewed (MR12, MR13, and MR14), and failed to follow their policy and procedure for providing emergency medical care by not continually reassessing abnormal vital signs for two of eleven medical records reviewed. (MR3 and MR17)
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Findings include:

Review of facility policy and procedure "Admission, Discharge, Reservation, and Transfer of Patients" last approved May 2019, revealed "18. Patients shall only be discharged/transferred following a physician order."

1. Review of MR12, MR13, and MR14 on May 15, 2019, revealed the patients were transferred on April 13, 2019. Further review revealed no documentation of a physician order to transfer the patient, as per above policy.

2. Interview with EMP1 on May 16, 2019, at 9:35 AM confirmed the above findings and revealed, "when they put in the disposition as transfer they [the physicians] feel it is the order."

Review of facility policy "Triage and Vital Sign Assessment and Documentation" last reviewed August of 2018 revealed, "..Repeat vital signs are done according to the following schedule regardless of previously indicated time interval ...B. Abnormal Parameters 1. Vital signs (except temperature) are repeated within 30-60 minutes if not within the normal range for age...3. Notify physicians of all patients with abnormal vital signs... ."

1. MR17 presented to the facility's Emergency Department (ED) on January 24, 2019, at 19:51 after being involved in a motor vehicle collision and chief complaint on presentation to the ED was neck pain.

2. Review of MR17 revealed that at 19:59 on January 24, 2019 MR17's vital signs were assessed by facility and blood pressure was documented as 207 Systolic over 106 Diastolic.

3. Further review of MR17 revealed the patient was discharged from the ED at 23:33 and no reassessment of vital signs was completed by staff prior to discharge.

4. At 23:33 On January 24, 2019 an ED Physician Note revealed "BP 207/106, no repeats. Pt does have hx of HTN [hypertension]. Not addressed. Notify pt to f/u with PCP. Call #1: Contacted patient via cell phone and [patient] endorsed understanding that ...blood pressure was elevated ... "

5. MR3 presented to the facility's ED on April 8, 2019, and chief complaint on presentation to the ED was substance abuse.

6. Review of MR3 revealed that at 15:09 on April 8, 2019 vital signs were assessed by facility staff and blood pressure was documented as 151 Systolic over 104 Diastolic and heart rate was documented as 140.

7. Further review of MR3 revealed the patient was discharged from the ED at 15:49 and no reassessment of vital signs was completed by staff prior to discharge.

8. Interview was conducted with EMP1 on May 16, 2019 at 12:05 PM. EMP1 confirmed above findings.