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Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to have a physician order for restraint of one of four applicable medical records reviewed (MR9).

Findings include:

Review on February 20, 2020, of the facility policy "Patient Rights and Responsibilities," last reviewed February 13, 2020, revealed "... II. Policy: All patients should receive quality health care, according to need, regardless of race, age, ethnicity, religion, sex, sexual orientation, culture, language, physical or mental disability, socioeconomic status, and gender identity or expression. Patients will be treated as individuals, and the medical center recognizes their very unique needs and desires and strives to meet their needs to the best of our ability ... A Statement of Patient Rights ... Care Delivery ... Receive care free from restraints or seclusion unless necessary to provide medical, surgical or behavioral health care ..."

Review on February 20, 2020, of the facility policy "Restraint and Seclusion Policy," last reviewed August 23, 2019, revealed "II. Policy: The policy and practice associated with the use of restraint, seclusion and restraint and seclusion at Lehigh Valley Hospital - Schuylkill are designed to maintain the rights, dignity, and wellbeing of our patients, are committed to the prevention, reduction and elimination of restraint and/or seclusion and are fully supported by organizational leadership. When clinically appropriate in adequately justified situations and after all other non-physical alternatives have been exhausted the least restrictive method of restraint that meets the needs of the patient will be applied following an assessment by a qualified RN, qualified Physician Assistant (PA) or Licensed Independent Practitioner (LIP) ... III. Definitions: ... 9. Physical / Therapeutic Hold: The intentional physical holding down of a patient for care or treatment purposes such as administration of medication for agitation will be deemed a restraint and as such will require an order by an [sic] LIP for use of Physical Hold ... IV. Procedure: 1. Non-Violent/Non-Self Destructive A. Restraint Alternatives ... 2). If restraint alternatives are unsuccessful, the RN must reassess the patient, paying particular attention t the special needs of vulnerable patient populations such as emergency, pediatric and cognitively or physically limited patients to determine whether or not clinical justification for application of a restraint exists ... C. Restraint Orders: 1). A physician order is required for all patient restraints. a.) The use of restraint must be in accordance with the order from a physician or other LIP who is responsible for the care of the patient and who is authorized to order restraint or seclusion ..."

Review of MR9 on February 21, 2020, revealed this patient was seen in the Emergency Department (ED) on January 21, 2020, for treatment of a laceration of the head. A progress note indicated the patient was autistic and very difficult to hold still. Five staff members and a family member physically held the patient while the laceration was being stapled. Further review of MR9 revealed no order for the physical hold of this patient.

Interview with EMP5, at 10:40 AM, on February 21, 2020, confirmed there was no order for the physical hold of MR9.

Interview with CF2, at 9:00 AM, on February 21, 2020, revealed they were working the day MR9 was seen in the ED. CF2 confirmed MR9 was held down by multiple staff to complete the stapling of the patient's laceration. CF2 confirmed there was no order to physically hold MR9 for this procedure.


Repeat citation July 25, 2019.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the medical staff failed to adopt a policy that defined the expectations for evaluation, treatment and discharge instruction of patients presenting to the Emergency Department (ED) with head injuries, resulting in inconsistent treatment to patients with head injuries for 12 of 12 pertinent medical records reviewed (MR1 through MR12).

Findings include:

A review on February 20, 2020, of the "Amended and Restated Bylaws Schuylkill Medical Center-South Jackson Street," last reviewed November 2019, revealed "... Article VIII. Medical Staff Section 1. Medical Staff. The Board shall appoint an organized medical staff (the "Medical Staff") for the Hospital which shall operate in accordance with Medical Staff Bylaws ("Staff Bylaws") which shall be approved by the Board and by the Sole Member. The Medical Staff shall operate as an integral part of the Hospital and through its committees and Officers, shall be responsible for and accountable to the Board for the quality of medical care provided to patients of the Hospital ..."

Review of the "Medical Staff Rules and Regulations," last reviewed November 18, 2019, revealed "Introduction a. These Medical Staff Rules and Regulations are parameters for the conduct of professional clinical activities at the Hospital ... F. Emergency Department ... 3. Every patient presenting to the Emergency Department for care must be examined by a credentialed member of the Medical Staff, the Resident Staff, or the Allied Health Professional Staff ... 13. Diagnostic tests will be done in the Emergency Department when necessary for timely diagnosis and treatment ... H. Records ... 2. (d.) Emergency Department Records ... For an emergency patient, documentation of patient's evaluation, diagnosis and treatment along with discharge instructions, will be the responsibility of the Medical Staff Member caring for the patient ..."

Review on February 21, 2020, of facility "Discharge of Patients From the Emergency Department - Emergency Medicine," last reviewed October 9, 2019, revealed "... II. Policy: To assure a consistent process of discharge of emergency department patients. All patients discharged from the emergency department will have an appropriate follow-up plan of care discussed with them prior to discharge. ... IV. Procedure: ... 3. Discuss discharge instructions and plan with patient and/or appropriate responsible parties. ... 7. Give copy of discharge instructions and al prescriptions as indicated to the patient/family ..."

Review on February 19, 2020, of MR1 revealed this 59-year-old patient was seen in the ED on January 7, 2020, for injuries sustained in a fall downstairs. The patient sustained a laceration to the right outer ear and an abrasion to the right parietal scalp area. The patient was nonverbal and accompanied to the ED by a caregiver from the patient's group home. No computerized tomography (CT) scans or x-rays were completed. The laceration was cleansed, and then was closed. The patient was discharged at 0729 on January 7, 2020. Discharge instructions for wound care were given. No instructions on monitoring for head injury symptoms were given on discharge.

Review of MR1's medical record from an outside hospital revealed this patient required examination in another Emergency Department at 1224 on January 8, 2020. The patient had symptoms of stumbling, not moving head as normal and signs of pain. CT scans of the head and cervical spine were completed, and the patient was diagnosed with a subdural hematoma and a fracture of the cervical spine. The patient required transfer to a trauma center on January 8, 2020, for further treatment.

Review on February 19, 2020, of MR2 revealed this 76-year-old patient was seen in the ED on January 6, 2020, for an injury to the head, after a fall. This patient was verbal and complained of back pain and dizziness. No open skin areas were noted. CT scans of the head and lumbar spine were completed. Discharge instructions were given for fall prevention. No instruction to observe for neurological changes were given on discharge.

Review on February 19, 2020, of MR3 revealed this 79-year-old patient was seen in the ED on January 6, 2020, for a contusion and abrasion to the head, after a fall. This patient was verbal and offered no complaint of pain. CT scan of head was completed. Discharge instructions were given for care of a contusion. No instruction to observe for neurological changes were given on discharge.

Review on February 19, 2020, of MR4 revealed this 4-year-old patient was seen in the ED on January 6, 2020, with a head laceration, after a fall. The patient was verbal. No imaging studies were completed. Discharge instructions for care of a child with a minor head injury were given [won't stop crying, becomes very sleepy, complains of dizziness, becomes restless or confused, complains of head or neck pain or stiffness or vomits].

Review on February 19, 2020, of MR5 revealed this 73-year-old patient was seen in the ED on January 7, 2020, with a scalp abrasion, after a fall out of bed. This patient was non-verbal. No caregiver from the patient's group home accompanied this patient. CT scans of head and cervical spine were completed. Discharge instructions were given for care of an abrasion. No instruction to observe for neurological changes were given on discharge.

Review on February 20, 2020, of MR6 revealed this 41-year-old patient was seen in the ED on January 7, 2020, for a laceration of the head. Patient hit self on the head with a guitar. This patient was alert and verbal. The laceration was closed after application of a local anesthetic. No CT scan or x-ray were completed. Patient left the ED without their discharge instructions.

Review on February 20, 2020, of MR7 revealed this 48-year-old patient was seen in the ED on January 20, 2020, for a contusion to the head following a fall and hitting head and back on concrete. This patient was verbal. Pain medication was given to this patient. CT of the spine and head were completed. Discharge instructions were for care of a contusion. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR8 revealed this 80-year-old patient was seen in the ED on January 20, 2020, for an eyebrow laceration sustained in a fall. This patient was verbal and reported no loss of consciousness. The laceration was repaired. CT of the spine and head were completed. Discharge instructions for care of the laceration were given. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR9 revealed this 20-year-old patient was seen in the ED on January 21, 2020, for a laceration to the head. This patient was non-verbal. Family was unsure if patient sustained the injury in a fall. The laceration was closed with staples after being cleansed. An attempt to apply an anesthetic to the area was made. A progress note indicated the patient was autistic and very difficult to hold still. Five staff members and a family member physically held the patient while the laceration was being stapled. Discharge instructions for care of the laceration were given. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR10 revealed this 3-year-old patient was seen in the ED on January 21, 2020, for a laceration of the ear following a fall from a bed. Family reported the patient hit their head on a dresser. The ear laceration was closed with sutures after application of a local anesthetic. No CT scan or x-rays studies were completed. Discharge instructions for care of the laceration were given. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR11 revealed this 41-year-old patient was seen in the ED on January 20, 2020, for a minor head injury from a fall. This patient was non-verbal and was accompanied to the ED by a caregiver from the patient's group home. No CT scan or x-rays were completed. Discharge instructions included monitoring for neurological changes.

Review on February 20, 2020, of MR12 revealed this 96-year-old patient was seen in the ED on January 8, 2020, for a head contusion following a fall. This patient was verbal. CT of the cervical and lumbar spine were completed. Discharge instructions were for care of a contusion. No instruction to observe for neurological changes were given.

Interview with EMP5 on February 19, 2020, at 3:15 PM, confirmed MR1 through MR5 were seen in the ED for a type of head injury. EMP5 confirmed MR2, MR3 and MR5 had CT scans of their head or spine and MR1 and MR4 did not have a CT scan of the head.
EMP5 confirmed MR4 received discharge instructions for monitoring a child with a head injury for the next 24 hours. EMP5 confirmed MR1, MR2, MR3 and MR5 did not receive instructions to monitor for neurological changes.

Interview with EMP5, at 10:40 AM, on February 20, 2010, confirmed MR6 through MR12 were seen in the ED for a type of head injury. EMP5 confirmed MR7, MR8 and MR12 had CT scans of their head and/or spine, and MR6, MR9, MR10 and MR11 did not have a CT scan or x-ray of the head or spine. EMP5 confirmed MR11 received discharge instructions to monitor the patient for neurological changes. EMP5 confirmed MR7, MR8, MR9, MR10 and MR12 did not receive instructions to monitor for neurological changes. EMP5 confirmed patients with head injuries received varying types of evaluation, treatment and discharge instruction. EMP5 confirmed the facility does not have a policy or protocol to follow for treatment of patients with head injuries.

Interview with CF2, at 9:00AM, on February 21, 2020, confirmed ED patients may receive varying treatments for their head injuries and the ED does not have a policy or protocol to follow for evaluation, treatment and discharge instruction of patients with head injuries. CF2 stated they were going to develop a head injury protocol.

Interview with EMP1 on February 21, 2020, at approximately 1:35 PM, confirmed MR1's discharge instructions did not include observation for neurological changes. EMP1 confirmed the electronic medical record system chooses the discharge instructions according to the diagnosis. If the diagnosis was listed as a laceration or a contusion, and not head injury, only the laceration or contusion discharge instruction would be generated and given to the patient.

Based on facility documents, medical record (MR) review and staff (EMP) interview, it was determined the facility failed to ensure documentation of the verbal consent for treatment obtained via telephone included the name of the person giving the consent, their relationship to the patient, and the reason the written consent could not be obtained for two of 12 medical records reviewed (MR1 and MR5).

Findings include:

Review on February 21, 2020, of facility "Consent For Treatment - General," last reviewed August 26, 2019, revealed "...II. Policy: Policy Statement: Upon arrival to the hospital, the patient will be asked to sign a consent form for general treatment before such treatment can be initiated. Everyone eighteen (18) years of age or older, being of sound mind, had the right to decide whether to consent to medical diagnosis and treatment. III. Definitions: Incompetent - a condition in which an individual despite being provided appropriate medical information, communication supports, and technical assistance, is documented by a health care provider to be unable to understand the potential material benefits, risks, and alternatives involved in a specific proposed health care decision; unable to make that health care decision on his own behalf; or unable to communicate that health care decision to any other person. IV. Procedure: Guidelines: ... 6. In unusual circumstances when consent cannot be obtained in writing, in a timely manner, consent may be obtained by telephone. The telephone conversation shall be witnessed by an individual other than the individual obtaining the consent. The witness to the consent shall be identified to the person giving consent. The person giving consent shall be identified by name and relationship to the patient in the patient's medical record along with the reason why written consent could not be obtained and the nature of the consent obtained ..."

Review on February 19, 2020, of MR1 revealed the patient was nonverbal and accompanied to the ED by a caregiver from the patient's group home. The Consent for Treatment revealed documentation of verbal consent by telephone. There was no documentation of the name of the person giving the verbal consent, their relationship to the patient and the reason written consent could not be obtained.

Interview with EMP1 on February 20, 2020, at 2:40 PM, confirmed the Consent for Treatment for MR1 was a verbal consent received by telephone; there was no documentation of the name of the person giving the verbal consent, their relationship to the patient and the reason written consent could not be obtained.

Review on February 19, 2020, of MR5 revealed the patient was nonverbal. The Consent for Treatment revealed documentation of verbal consent by telephone. There was no documentation of the name of the person giving the verbal consent, their relationship to the patient and the reason written consent could not be obtained.

Interview with EMP1 on February 20, 2020, at 2:40 PM, confirmed the Consent for Treatment for MR5 was a verbal consent received by telephone; there was no documentation of the name of the person giving the verbal consent, their relationship to the patient and the reason written consent could not be obtained.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to adopt a policy that defined procedure requirements and expectations for patients presenting to the Emergency Department (ED) with head injuries.

Findings include:

Review on February 20, 2020, of the Emergency Department (ED) Policy and Procedure Manuel revealed no policy for care of a patient with a head injury.

Interview with CF2, at 9:00 AM, on February 21, 2020, confirmed the hospital's medical staff had not developed policies and procedures governing the medical care to be provided to patients presenting to the ED with head injuries.

Review on February 19, 2020, of the ED log for January 6, 7, 8, 20, 21, 2020, revealed 13 patients presented to the ED with head injuries on those days.

Cross reference
Tag 0347 - 482.22(b)(1)(2)(3) Medical Staff Organization and Accountability