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Based on review of facility documents and interview with facility staff (EMP), it was determined that the facility's governing body failed to annually evaluate the chief executive officer, who is responsible for managing the hospital.

Findings Include:

Review of "Restated Bylaws of Windber Hospital, Inc." dated January 5, 2022, revealed, "... Article IV-Board of Directors ... Section 2. Duties ... The Board of Directors of the Corporation shall serve as the governing body of the Corporation, and in connection therewith, the Board of Directors shall, subject to the reserved powers of the Member, in addition to taking other action in furtherance of the purposes of the Corporation: ... (g) Annually evaluate the performance of the CEO ... Article VII. Officers ... Section 8. Chief Executive Officer. The Chief Executive Officer shall be appointed by the Board, with the consent of the Member, and shall be a Director ex officio with vote. ... ."

Review of "Position Description" for President/Chief Executive Officer Administration," dated October 2013, revealed, "Mission and Vision Statement: WMC is a nonprofit, community healthcare provide. We are dedicated to providing excellence in personalized, quality healthcare services through innovation, research, and education in response to community need. WMC will be the preferred provider for extraordinary patient and family centered care. Core Values: Patient and Family Centered We respect each patient and family. We are committed to integrating traditional medicine with complementary services, and delivering care in a healthy and healing environment. Service Excellence We strive to anticipate, meet and exceed the needs of our patients, physicians, co-workers and community and will consistently provide quality care and service. We adhere to the highest standards of clinical competency and responsiveness. Integrity We are honest, respectful and trustworthy, and will maintain the highest ethical standards. Compassion We care for others with dignity and empathy. Respect We treat each individual, those we serve and those with whom we work, with the highest professionalism and dignity. Innovation We are creative, progressive and will embrace change. Collaboration We work together with board, clinical, education, business and research partners to foster an environment of mutual respect and support in order to assure a broad range of quality care and services. Stewardship We are careful with how we utilize the resources of time, talent, money, property and the environment. Overall Purpose of Job: This position assumes the overall responsibility for accomplishment of the organizational mission, consistent with the best interests of patients, the community, and employees. This position plans, organizes, and controls the organization's structure and operations. Engages in marketing and program development activities to ensure continued success of WMC. Establishes and promotes effective communications with the medical staff. Essential Functions of Job: (other duties may be assigned) 1. Develop long term strategic direction for the organization in conjunction with the Board of Directors, executive management, and other key stakeholders. Key Measures: Continuously monitor the strategic direction of the organization. Communicate to the Board monthly and update the strategic plan as necessary. Evaluate direct reports on strategic plan communications to all employees. 2. Provide a market focus to the organization by maximizing the market share of WMC. ... Assess health care needs of the community and develop or revise marketing plans at least annually. ... 3. Continuously monitor operational and financial performance indicators for the organization's long term growth and viability. ... 4. Provide visionary leadership to the organization. ... Develop the organizational structure through the empowerment of leadership. ... Seek Board approval as necessary. Direct the development of organization-wide performance standards. ... Maintain effective contacts with hospital associations, regulatory agencies, and governmental authorities. ... 6. Provide leadership and management of direct reports. ... 10. Direct the quality initiatives of the organization. ... Assure that quality indicators are being monitored and reported to the Board via the Quality Committee on a quarterly basis. ... 12. Continuously ensure WMC is meeting all regulatory requirements associated with its operation. ... Assure compliance with Department of Health and other accrediting agencies. Other Duties of Job: 1. Perform other related duties as assigned or required. 2. Follow standard precaution guidelines. Supervision is received by the Board of Directors ... Knowledge, Skills, and Abilities Required: 1. Knowledge of JCAHO and other applicable regulatory agencies. ... 10. Excellent leadership and interpersonal skills. ... I will perform all duties to the best of my ability. ... ."


1. A request was made to the facility by the surveyor on September 7, 2022, and September 12, 2022, for documented evidence of the Board's annual performance evaluation of the CEO as stated in the above bylaws.

Onsite interview on September 7, 2022, and telephone interview on September 12, 2022, both with EMP1, confirmed there was no documented evidence that the Board ever conducted an annual performance evaluation for EMP4.

Based on review of facility documents and interview with facility staff (EMP), it was determined that the facility failed to ensure that services performed under contract were provided in a safe and effective manner, by failing to renew the contract of the chief executive officer.


Findings Include:

Review of "Restated Bylaws of Windber Hospital, Inc." dated January 5, 2022, revealed, "... Article IV-Board of Directors ... Section 2. Duties ... The Board of Directors of the Corporation shall serve as the governing body of the Corporation, and in connection therewith, the Board of Directors shall, subject to the reserved powers of the Member, in addition to taking other action in furtherance of the purposes of the Corporation: ... Section 8. Chief Executive Officer. The Chief Executive Officer shall be appointed by the Board, with the consent of the Member, and shall be a Director ex officio with vote. The CEO shall have the authority and responsibility necessary to operate the Corporation in all its activities and departments, similar to the chief executive officer of a business corporation, subject only to such policies as may be issued by the Board or its Executive Committee and in compliance with all applicable laws and regulations. The CEO shall have the education and experience necessary to carry out the responsibilities of the position. In addition, The CEO shall: ... (c) Be responsible for the implementation of established policies in the operation of the Hospital; (d) Serve as the liaison among the Board, Medical Staff, Administrative Staff, and departments within the Hospital; (e) Provide for the organization of the administrative functions of the Hospital including appointment of administrative staff and the establishment of formal lines of responsibility and accountability; (g) Perform such other duties as the Board of Directors shall from time to time direct; (h) Be responsible, except as otherwise provided by the Board, for selecting, employing, controlling and discharging employees and for the development and maintenance of personnel policies and procedures; and (i) Ensure that agreements with providers of services to the Hospital specifically indicate that compliance will be maintained as would apply to the same services if provided directly by the Hospital. ... ."



1. Review of EMP4's "Employment Agreement-Windber Medical Center [the Company]," dated July 21, 2014-June 30, 2017, revealed, "... The employee hereby accepts such employment and agrees to undertake the duties and responsibilities inherent in such position and such other duties and responsibilities as the Board shall from time to time reasonably assign to him. The Employee agrees to devote his entire business time, attention and energies to the business and interests of the company during the Employment Period. The Employee agrees to abide by the rules regulations, instructions, personnel practices and policies of the company and any changes therein that may be adopted from time to time by the Company. The Employee acknowledges receipt of copies of all such rules and policies committed to writing as of date of this agreement ... ."
Telephone interview with EMP1 dated September 12, 2022, at 8:40 AM confirmed that the contract dated July 21, 2014-June 30, 2017, was the only contract the facility had for EMP4.

Based on review of facility documentation and patient's medical record (MR) and interview with facility staff (EMP), it was determined that the facility failed to ensure that the patient's exercise of patients' rights were met by failing to follow adopted polices and Scope of Service to ensure the effective use of time and avoidance of personal discomfort by failing to to implement emergency procedures without delay by failing to follow their adopted policy to initiate a rapid response and by failing to competently administer suction to a patient requiring that intervention in one of one medical record (MR1)


Findings Include:


Review of "Windber Hospital, Inc. Administrator Polices and Procedures ... Policy Number: 1.53 ... Subject: Patient Bill of Rights policy and procedure," dated January 2021, revealed "Purpose: To ensure that all patients understand their rights and responsibilities while a patient and how they will be treated professionally and personally in the rendering of medical care. ... Principles Guiding Patient Rights and Responsibilities Windber Hospital, Inc. subscribes to the following principles: I. The patient, as a human being, is entitled to be treated with dignity, respect, and consideration; and with recognition of his/her integrity as an individual. ... Principle I A patient, as a human being, is entitled to be treated with dignity, respect, and consideration; and with recognition of his/her integrity as an individual. a. The organization's policies and procedures are formulated to afford the patient consideration and respect by the staff during the course of every phase of the patients' care. b. The organization has procedures to ensure that patients' requests are received and properly considered as quickly as circumstances permit. ... Principle II A patient is entitled to participate in making decisions affecting his/her healthcare, and well-being, to the extent that he/she is capable. ... b. The patient is entitled to have questions answered about his/her condition and course of treatment and prognosis (including information about alternative treatments and possible complications) in layman's terms. It is the responsibility of the patient's physician to maintain communication with the patient regarding such condition and care. ... d. The patient has the right to expect emergency procedures to be implemented without unnecessary delay. .... A Statement of Patient Rights ... 2. You have the right to expect safety, privacy and confidentiality with regard to all aspects of your care. ... 3. You have the right to timely care and high professional standards. ... 7. You have the right to be informed of your health status by your doctor. ... ."


Review of "Position Description" for Registered Nurse Wing 3," dated September 2014, revealed, "Vision Statement: Windber Medical Center [WMC] provides full-service community hospital capabilities to northern Somerset County and surrounding areas. WMC adds value through geographically dispersed access points, a unique level of service excellence, regional niche development, operational efficiency, innovative development of delivery models of care, and a lasting commitment to the health and wellness of its community through care to the whole person, body, mind and spirit. Core Values: 1. Respectful Treat all patients, employees, and visitors to WMC with courtesy and respect by showing compassion and kindness to people at all times. 2. Trustworthy Build relationships with patients and co-workers by being honest, trustworthy, and sincere in both words and action. Strive to be known for personal integrity. ... 3. Professional Strive for education and knowledge in field of expertise. Gain knowledge to insure competency, which leads to professionalism. Attend trainings, in-services, meetings, and conferences as necessary and as directed. 4. Show support and empathy to patients and co-workers. Is helpful and goes the extra mile to exceed someone's expectations. ... Supports the safety initiatives of WMC by adhering to safety, health, wellness work practices and identifying and reporting any safety risks to either a member of the Safety Committee or the immediate supervisor. ... Overall Purpose of Job: This position must assume responsibility of meeting patient needs efficiently by applying complete nursing care to assigned patients. Care must be provided through all life stages of ages in medical, surgical, and telemetry areas of nursing. This position also provides direction and oversight to other staff members regarding patient care. Essential Functions of Job: (other duties may be assigned) 1. Actively participate in patient care. Key Measures: Communicate pertinent information both orally and written to appropriate staff daily. Report change in patient condition, fall, categories, transfers to other departments, staffing problems, etc. to health team daily. ... ."


Review of "Windber Hospital, Inc. ... Nursing Policies and Procedures ... Subject: Code Blue Personnel Response policy and procedure," dated January 2021, revealed "Purpose Windber Hospital Inc. (Windber) has established a plan of response for Code Blue situations in which certain staff members from each department are appointed to assist. A Code Blue alert shall take priority over other responsibilities at that time. The primary nurse for the patient in need shall initiate Cardio Pulmonary Resuscitation, until the "team" arrives. When the "team" has assembled, authority and responsibility for management lies with the team leader (physician). Policy 1. The following is an overview of designated responders. A. 7-3 Shift Assigned Nursing Personnel from each unit Emergency Department staff member, CCU nurse if available, and ED physician Attending In-House Physicians, if available EKG, if available Respiratory Therapy Anesthesia, if available Hospital Supervisor, assuming pager responsibilities for the shift. B. 3-11 Shift and 11-7 Shift Hospital Supervisor -1500-0700 Monday-Friday, 24 hours' weekends Assigned Nursing Personnel from each unit. Emergency Department staff member, ED Physician, and CCU nurse if available. Attending In-House Physicians, if available. Respiratory Department, if available 2. When a physician is not available, the CCU nurse or ED nurse will begin ACLS protocols until arrival of a physician. ... ."


Review of "Position Description" for Respiratory Therapist," dated September 2014, revealed, "Vision Statement: Windber Medical Center (WMC) provides full-service community hospital capabilities to northern Somerset County and surrounding areas. WMC adds value through geographically dispersed access points, a unique level of service excellence, regional niche development, operational efficiency, innovative development of delivery models of care, and a lasting commitment to the health and wellness of its community through care to the whole person, body, mind and spirit. Core Values: 1. Respectful Treat all patients, employees, and visitors to WMC with courtesy and respect by showing compassion and kindness to people at all times. 2. Trustworthy Build relationships with patients and co-workers by being honest, trustworthy, and sincere in both words and action. Strive to be known for personal integrity. ... 3. Professional Strive for education and knowledge in field of expertise. Gain knowledge to insure competency, which leads to professionalism. Attend trainings, in-services, meetings, and conferences as necessary and as directed. 4. Show support and empathy to patients and co-workers. Is helpful and goes the extra mile to exceed someone's expectations. Work as a team member to meet goals of WMC. Always recognizes and celebrates success. Supports the safety initiatives of WMC by adhering to safety, health, wellness work practices and identifying and reporting any safety risks to either a member of the Safety Committee or the immediate supervisor. ... Overall Purpose of Job: This position has the responsibility of being a staff therapist in the Respiratory Care department. It also has the responsibility of meeting the needs of patients effectively and efficiently by applying all aspects of Respiratory Care to assigned in-patients and out-patients. Patient care includes all medical therapies, educational information, Oxygen therapies, specialized procedures, and outreach programs within the scope of practice. As per departmental policy, on-call will be part of this position's responsibilities. Essential Functions of Job: (other duties may be assigned) 1. Perform daily Oxygen therapy. Key Measures Conduct Oxygen therapy rounds daily. Monitor medical gas supply, conduct an inventory of the medical gas supply, and order the appropriate amount. Set up/maintain equipment such as Oxygen tents, ventilators, and room humidifiers per physician orders. Provide an explanation of procedure/equipment to patient and complete necessary paperwork. ... Check pulse oximeter of every patient that is utilizing Oxygen therapy to assure adequate supplemental Oxygen is given, Oxygen is still indicated, and to maintain cost effectiveness. ... Make sure the equipment is in working order and all paperwork needed is available. ... 2. Conduct respiratory treatments as necessary. Key Measures: Issue Intermittent Positive Pressure Breathing prescriptions and perform Chest Physical Therapy, Incentive Spirometry, Peak flows, and Pep Therapy. ... Assemble the necessary equipment, complete the proper charting paperwork and check with the physician orders to confirm. Perform the therapy ordered and record the date, time, medication, duration, breath sounds, patient reaction/toleration, heart rate, cough, and sputum production, chart reviewed. Instruct patients on proper use of respiratory medications. 3. Conduct diagnostic testing as necessary. Key Measures: ... Conduct inpatient and outpatient ABG studies. Apply supplemental Oxygen and pulse oximetry as needed. ... Monitor the patient's heart rate, blood pressure, and saturated Oxygen during all testing procedures. ... 4. Complete Respiratory Care housekeeping duties. Key Measures: ... Assist with reviewing department policy and procedure policy and procedure manual as needed. Work weekends, shifts, holidays, and take call as scheduled/necessary. ... Assist other health care professionals in any way. Maintain equipment. ... 5. Complete ventilator/BiPAP care as necessary. Key Measures: ... Transport patients if necessary making sure patient is suctioned and well oxygenated. ... 8. Respond to all emergency situations. Key Measures: For code blues report to area, prepare with PPE and be ready to assist intubation. Clean up, replace equipment used, and charge the equipment following the code blue. Maintain patients' airway, perform CPR, and obtain ABG. ... Other Duties of Job: 1. Assist supervisor of Respiratory/EKG/Sleep with what he/she deems necessary to run the department smoothly. ... 3. Participate in on call for the department. ... Knowledge, Skills, and Abilities Required: ... 4. Ability to define problems, collect data, establish facts, and draw valid conclusions. ... 7. Ability to effectively deal with end-of-life situations. ... 10. Working knowledge of Diagnostic test, treadmills, and medical gases. ... ."

Review of "Windber Hospital, Inc. ... Respiratory Care Policies and Procedures ... Policy Number: 1.00 ... Subject: Respiratory Scope of Care," ... Revised: June 2012 ... Reviewed: January 2021, revealed "Policy Respiratory Therapists are health care professionals whose reponsibilities include diagnostic evaluation, management, education, rehabilitation, and care of patients with deficiencies and abnormalities of the cardiopulmonary system. The scope of care as provided by the respiratory care department encompasses activities in diagnostic evaluation, therapy, and education of patient, family, and public. These activities are supported by respiratory education and certifications. Windber Hospital Inc.'s (Windber) respiratory care department provides comprehensive diagnostic, therapeutic, and rehabilitative services to inpatients and outpatients and those whose conditions are either chronic or acute. The department is divided into 3 divisions under the scope of respiratory care each providing services as follows: Respiratory Therapy Therapeutic services for inpatients and outpatients with acute and chronic respiratory conditions, including emergencies. Respiratory treatments ... Oxygen therapy Pulse Oximetry ... Medical Gas Safety ... Respiratory Medication delivery Respond to Medical Emergencies Obtain BLS and ACLS training ... Secretion management ... Performance Improvement RN Orientation Continuous Education ... Diagnostics ... Pulmonary education ... Spirometry Studies ... Cardiac/EKG ... Electrocardiogram/EKG ... Staffing Respiratory Care: Monday through Friday 6a-10p; Saturday and Sunday 6a-6p. When treatment load is low or census is low respiratory care staffing may be adjusted at the discretion of the respiratory care manager. ..."

Review of "Windber Hospital, Inc. ... Administrative Policies and Procedures ... Policy Number: 1.56 ... Subject: Rapid Response Team," dated April 2021, revealed "Purpose: It is the policy of Windber Hospital, Inc. to have mechanisms for improving patient care outcomes and preventing serious events and deaths for our patients. ... Definition: Rapid Response Team-brings critical care expertise to the patient bedside, or wherever needed, to assess, evaluate, stabilize, communicate, educate, support, and transfer, if necessary. The intent of the Rapid Response Team is to support the clinical staff, as well as, the patient. Patients are oriented to the procedure by the admission nurse. Calling the Rapid Response Team: A. The Rapid Response Team consists of the Hospital Supervisor and primary care nurse, along with additional staff as determined after the initial assessment by Hospital Supervisor. Other team members may include: ED Physician, Respiratory Therapist, Anesthesia, Lab Tech, Radiology, and CCU/ED Nurse who may be notified via overhead announcement; 'Rapid Response and Location.' B. Call the Rapid Response Team by: Calling the Hospital Supervisor cell phone at 814-341-1641 C. The person requesting the team will remain with the patient for assistance and patient information. ... D. Criteria for calling the Rapid Response Team may be, but not limited to: Staff or patient's significant other who are concerned or worried about the patient's condition. Heart rate less than 40 or greater than 160 beats per minute Acute change in systolic blood pressure less than 90 mmHg or greater than 200 mm Hg or diastolic blood pressure greater than 110 mmHg. Acute change in respiratory rate less than 8 breaths per minute or greater than 28 per minute or greater than 28 per minute Acute change in saturation (less than 90%) for greater than five minutes ... E. The Team will initiate the Rapid Response Team Orders/Protocol. ... Attachment to the policy was a document entitled, "Rapid Response Protocol Orders" revealed, "... Respiratory Distress Oxygen 15 L NRB (acute change in O2 saturation less than 90% despite 02 for greater than 5 minutes or respiratory rate less than 8 breaths per minute or or greater than 28 breaths per minute). ... ."

Review of the "Crash Cart Checklist" for the Radiology Department included, "Defib Function ... Cables Intact ... Defibrillator Paper Present ... Electrodes Present ... Defib Pads Present ... All Locks Intact ... O2 Tank Full ... Pediatric Paddles Present ... Binder Present ... CPR Board Present ... Ambu Bag Present ... Clean Bi-Monthly ... ."



1. Review of MR1 revealed the patient's weight as follows:
April 10, 2022 171.8 pounds
April 15, 2022 171 pounds
April 17, 2022 192 pounds
April 18, 2022 186.6 pounds
April 19, 2022 190 pounds

There was no documented evidence in the patient's medical record (MR1) that addressed the patient's weight gain. MR1 revealed documented evidence that the patient experienced gradual edema to the ankles, then bilateral lower extremities and genitalia, post-operatively.


Interview of EMP1 via review of electronic mail documentation, dated August 18, 2022, at 9:48 AM confirmed the above finding and revealed, "... I didn't see any more documentation on the weight gain."



2. Review of MR1 respiratory therapist documentation revealed, "... 04/19/22 ...1857 ... Incentive Spirometry Assessment/Tx ... Not done. Patient vomiting at this time. ... Chest Physiotherapy Treatment ... Not done. Patient vomiting at this time. ... Respiratory Nebulizer Treatment ... Not done. Patient vomiting at this time. ... 1957 ... Patient was unable to get good pulse ox. tried on different finger, forehead, earlobe, pulse ox read at one point 68%, then mid to high 70s peaked at 91%. pulse ox is bouncing significantly. rn aware and calling md ... ."

3. Review of MR1 nursing documentation " ... 04/19/22 ... 2000 ... Cardiac Symptoms ... Tachycardia ... Low Blood Pressure ... Cyanosis ... Telemetry ... Y ... Rate ... 131 beats per minute ... Cardiac Additional Findings ... Trunk/head color WNL. Fingers and toes cyanotic & cold. ... Respiratory Symptoms ... Tachypnic [sic] ... Adventitious Breath Sounds ... Incr Work of Breathing ... Respiratory Rate ... 33 breaths per minute ... Depth ... Shallow ... Lung Sounds ... Coarse ... Rhonchi ... O2 Sat by Pulse Oximetry ... 70% ... 4.0 L/min ... RT at bedside. ... Code blue called at 2026. ... 2109 ... Date of Death ... 04/19/22 ... Pronounced By: ... ."


4. Review of "Windber Hospital Cardiopulmonary Arrest Flow Sheet," dated April 19, 2022, revealed, "... Time of Arrest: 2026 ... Ventilation: ... Ambu: X ... Intubation: ... Oral: X ... Time: 2057 ... Tube Size: 8.0 ... 2109 ... Personnel Involved in Code: ... "

Interview with EMP2 on July 2022, confirmed that the Respiratory Therapist was not included in the code blue participants as EMP5 clocked out at 8:11 PM and the code was called at 8:26 PM.

Telephone interview with EMP1 on August 17, 2022, at approximately 9:00 AM revealed that the RN supervisor present during the code later had discussion with the Respiratory Therapist regarding the employee's failure to assure the stability of the patient's respiratory status, by departing the facility at the end of scheduled shift, which was inconsistent with the facilities Respiratory Scope of Care. EMP1 followed up with statement, that the Respiratory Therapist that was scheduled the evening the patient coded was "not a strong therapist."


5. Review of the Respiratory Therapist staffing schedule for April 19, 2022, confirmed with EMP2 revealed EMP5 was scheduled at 12:00 PM until 8:00 PM which was not consistent with the Respiratory Scope of Care provided by the facility.

Interview with EMP2 on July 2022, revealed, "There is a Respiratory Therapist here Monday through Friday from 6:00 AM until 10:00 PM and Saturday and Sundays from 6:00 AM until 6:00 PM. Their hours have changed since covid. ... EMP5 was here on the 19th, EMP5 clocked out at 8:11 PM. ... No one was called to come in on the 19th. Our current hours have not been adjusted in our Scope of Practice. We changed the hours that the Respiratory Therapist is scheduled but we did not revise the Scope of Practice, that is correct. Our current hours were implemented after covid decreased. They work Monday through Friday 6A-2P, 7A-3P, 12P-8P and 8:30A-4P with on-call 8:00P-6:00A and Saturday and Sunday 6A-3P with on-call 3P-6A."

6. Review of MR1 failed to reveal documented evidence that a rapid response was initiated when the patient's pulse oximetry decreased less than 90% and respiratory rate increased over 28 per minute, requiring an increase in oxygen delivery as per policy.

Telephone interview with EMP1 on August 17, 2022, at 9:00 AM confirmed that a rapid response was not called and revealed, "A rapid response should have been called. They called the code blue."

7. Review of MR1 "Progress Notes" noted April 19, 2022, 9:18 PM revealed, "Code Blue Note: Code Blue was initiated at 20:26. The patient was encumbered on the CT table in a R lateral recumbent position with brown liquid pouring out of ... mouth. At least 3 L of fluid on the table and floor. The patient had agonal respirations and no pulse noted. CPR initiated by nursing staff. The patient had BVM [bag valve mask] initiated until suction was established. Suction on the wall failed and no further suction unit was available. ... BVM was continued and the decision was made to move the patient to the ED where suction and more resources available upon entering the ED, then CPR was continued. ... At 21:09, No cardiac activity noted and Asystole noted on monitor. The patient was declared dead at 21:09 on 4/19/22. ... ."

Interview with EMP1 on July 21, 2022, revealed, "We have never kept suction cannisters on the crash carts."

8. Interview of EMP2 via electronic mail documentation received on July 28, 2022, at 3:01 PM revealed, "... Inpatient cardiac arrest occurred in Radiology in the CAT scanner room. ... It was reported that suction was not operational during the code. ... Patient was taken to ED for further care. ... The radiology staff had replaced the canister and tubing and found the shut off valve on the regulator to be in the off position.


9. Interview of EMP1 via electronic mail documentation dated August 18, 2022, at 1:13 PM revealed, "... The lid of the canister was not securely on, the user did not wait and secure the lid to hear the clicks to secure it tightly."

Based on review of facility documentation and medical record (MR) and interview with facility staff (EMP), it was determined that the facility failed to follow adopted policies for medication administration by failing to administer, on 34 occasions, anti-hypertensive medication as ordered for elevated blood pressure in one of one medical record (MR1).

Findings Include:

Review of "Chan Soon-Shiong Medical Center at Windber Department of Pharmacy ... Medication Orders ... Policy #26A policy and procedure," dated February 2019, revealed "Policy ... 2. All medication orders for patients are written on the hospital-approved provider's order form or via electronic order entry by the prescriber, or an agent who is authorized to write orders by hospital policy and in accordance with state law. ... ."

Review of "Chan Soon-Shiong Medical Center at Windber Department of Pharmacy ... Medication Administration ... Policy #26B policy and procedure," dated February 2019, revealed "Purpose It is the policy of the Pharmacy Department to establish criteria for the administration of medication. Only authorized individuals will administer medications to patient. Policy Medications administered to patients are to be ordered electronically or in writing by a physician. ... Registered and Graduate Nurses may administer intravenous medications and intradermal medications. ... Professional and Practical Nurses must have a thorough knowledge of all medications adminstered to patients. This includes the action, indications for use, usual dose, method of preparation, rate & method of administration, expected results, and possible side effects. ... The nurse on duty should be conscious of how a patient is responding to their medications. If any actual or potential medication-related problems arise they should be resolved before the next administration of medicine. ... Although no problems may be apparently present upon observation; all nurses and health care professionals in patient's contact should continue to monitor the patient closely. It is possible for latent medication-related problems to appear after many doses of the drug. Nurses should communicate with the patient and gather opinions and perceptions about their treatment while also review their current medical records. ... ."

Review of "Position Description" for Registered Nurse Wing 3," dated September 2014, revealed "... Essential Functions of Job: (other duties may be assigned) ... 2. Administer medication and treatment daily as ordered by physician with proper documentation. Key Measures: Follow the five patient rights: right medication, right patient, right route, right dose, and right time. Complete documentation immediately following administration in in patient's chart. Sign and date all documentation. 3. Coordinate IV therapy Key Measures: ... Maintain 100% compliance with all Hospital policies and procedures. ... ."

1. Review of MR1 electronic physician orders revealed, "Metoprolol Tartrate (Lopressor Inj) 5 mg Q4 hours PRN for Systolic > 150 ... April 12, 20:15"

2. Continued review of MR1, blood pressure readings, was conducted to ascertain the frequency of administration of Metoprolol Tartrate 5 mg/ml vial (5 mg), 5 mg IV every four hours as needed for systolic blood pressure greater that 150 mmHg. Review of vital signs, revealed a total of 67 blood pressure readings from April 12, 2022, through April 19, 2022, roughly every four hours. Forty-eight of 67 blood pressures documented revealed a systolic blood pressure (SBP) greater than 150 mmHg. Of those 48 blood pressures, documentation revealed 14 blood pressures were treated with the administration of Metoprolol Tartrate 5 mg/ml vial (5 mg), 5 mg IV as ordered for SBP greater than 150 mmHg. There was no documented evidence that the remaining 34 blood pressures with SBP greater than 150 mmHg were treated as ordered.

Telephone interview with EMP1 on August 17, 2022, at approximately 9:00 AM confirmed the above findings.

Telephone interview with EMP3 on July 22, 2022, at 8:45 AM revealed, "... Some of the B/Ps get overlooked. The care techs get them and report them to us, but sometimes they do get missed. ... ."