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145 NORTH 6TH STREET

READING, PA 19601

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on a review of facility documents, review of medical records (MR), tour of facility and staff interview (EMP) it was determined that Haven Behavioral Hospital of Eastern PA failed to maintain a safe care setting as evidenced by a patient who was able to barricade self in their Day Room, unattended, and by facility's delayed response in opening the door.

Findings include:

On January 25, 2022, review of facility Safety Management Plan last approved March 2021 revealed, "The scope of the Safety Management Plan defines the processes which the Hospital utilizes to provide our patients, staff and visitors with a physical environment free of hazards and manages activities pro-actively through risk assessment to reduce the risk of injuries to patients, staff and other individuals coming to the hospital."

On January 21, 2022, review of facility Progress Report submitted by EMP5 on December 23, 2021 at 1530 revealed "At 1405 pt barricaded self in Dayroom. Patient would not respond when prompted by staff. Staff was unable to open door. Police/Fire Department arrived and had to break the door open. Patient was found on the counter with fabric around their neck. Sternal rub resulted in patient arousal. BP 154/90 P 130 Sp02 96% room air. Alert and oriented, reported some throat pain but refused meds."

Further review of MR1 Patient Observations sheet on December 23, 2021, 1400 noted patient lying/sitting in Dayroom; during times 1415-1500 noted patient agitated locked in self in Dayroom.

An interview was conducted with EMP1 on January 21, 2022. EMP1 confirmed information documented in the Progress Note for January 12, 2022 was an accurate account of what occurred during the incident on December 23, 2021. EMP1 also stated the reason staff was unable to get door open was because one of the chairs was wedged against a door stop on the floor.

On January 21, 2022 during a tour of the facility, the Dayroom (room 3314) was observed. This is the room that the patient was able to barricade self in. The door is solid wood and does not have a viewing window. Room 3314 is located directly across from Nurses Station, the staff can only view part of room. The Library (Room 3318) was also observed to have the same type of solid wooden door without a viewing pane. Books were observed on the shelves and a pile of books was noted to be stacked on the floor to keep the door open, along with multiple chairs. It was noted that patients had unsupervised access to the Library.

EMP1 confirmed that the door to the Library is the same type of door that they were unable to open when a patient barricaded self in the Dayroom, and that the books and chairs could be used to cause self harm or harm to other.

MEDICAL STAFF BYLAWS

Tag No.: A0353

Based on a review of facility documents, Medical Staff Bylaws, medical records (MR) and interview with staff (EMP) it was determined that Haven Behavioral Hospital of Eastern PA failed to ensure the medical staff enforced their Bylaws in regards to verbal orders and completion of medical records. ''


Findings:

On January 21, 2022 review of facility Haven Behavioral Hospital of Eastern PA, Medical Staff Bylaws, approved last January 2021 revealed "... 7.14 Completion of Medical Records -All discharge summaries and other medical record documentation shall be completed within thirty (30) days following the patient's discharge. Incomplete records exceeding thirty (30) days following discharge will be considered delinquent. Disciplinary measures, as specified in the Medical Staff Bylaws, will be instituted against the Practitioner who fails to complete medical records within the specified time frame. ... " The Medical Records Department shall notify Medical Staff Members in writing of incomplete medical records nearing delinquent status. This notification shall remind the Medical Staff Member that Clinical Privileges shall be automatically suspended in the event that he does not complete the medical records within five (5) working days following receipt of notice. If the Physician fails to complete medical records after such notification, all of his Clinical Privileges shall be automatically suspended. ... "Article IX Corrective Action- 4. Automatic Suspension and Expulsion.-The following conduct or events shall result in automatic suspension from Medical Staff membership and Clinical Privileges and shall not entitle the Affected Physician or Other Affected Practitioner to the Hearing and appeal rights specified in these Bylaws, unless otherwise expressly provided...1. Medical Records- Medical Staff Members must complete their patients' medical records, in accordance with all applicable Rules and Regulations and all applicable procedures of the Hospital and Medical Staff, within 15 days of each patient's discharge or within such other period as the MEC may prescribe from time to time. Medical records that the Medical Staff Member fails to complete within 15 days (or other specified time period) shall be considered delinquent. The Medical Records Department shall notify Medical Staff Members in writing of incomplete medical records nearing delinquent status. This notification shall remind the Medical Staff Member that Clinical Privileges shall be automatically suspended in the event that he does not complete the medical records within five (5) working days following receipt of notice. If the Physician fails to complete medical records after such notification, all of his Clinical Privileges shall be automatically suspended. ... ."


On January 21, 2022 review of MR 7 Physician Medication Orders sheet revealed a medication order was written by a nurse on November 4, 2021 at 08:07 that was never signed by a physician. Patient was discharged November 4, 2021 at 11:25 and the chart has not been completed by physician within 15 days after discharge per Medical Staff Bylaws. Also, per Medical Staff Bylaws medical records department did not notify physician in writing of incomplete medical records nearing delinquent status. As of January 21, 2022 no signature was noted for order which violates Medical Staff Rules and Regulations that all medical record documentation shall be completed within thirty (30) days following the patient's discharge.

On January 21, 2022 review of MR 8 Physician Medication Orders sheet revealed 13 Telephone medication orders were written by a nurse on December 7, 2021 at 11:48 and 12 Ancillary telephone ancillary orders written by a nurse on December 7, 2021 at 11:47 that were never signed by a physician. Patient was discharged December 22, 2021 at 12:07 and the chart has not been completed by physician within 15 days after discharge per Medical Staff Bylaws. Also, per Medical Staff Bylaws medical records department did not notify physician in writing of incomplete medical records nearing delinquent status. As of January 21, 2022 no signature was noted for order which violates Medical Staff Rules and Regulations that all medical record documentation shall be completed within thirty (30) days following the patient's discharge.


On January 21, 2022 review of facility policy Telephone and Verbal Orders last approved September 2021 revealed, "Procedure: Telephone and Verbal Orders/Read Back and Verification: Only telephone and verbal orders from an approved licensed independent practitioner (LIP) will be taken. Telephone and verbal orders shall be received and recorded immediately in the patient's medical record by the licensed nurse. Verbal orders are only used in an emergency situation. ... ."


Review of MRs 1-10 revealed verbal orders were entered during admissions for medications, treatments and ancillary orders.

Additional review of MR4, MR5, MR7, and MR9 showed that verbal orders were used for additional occurrences other than on admission in each of these medical records for non-emergent medication and ancillary orders.

Interview with EMP1 confirmed verbal orders were used for admission orders and non-emergent orders in ten out of ten medical records reviewed.

CONTENT OF RECORD: ORDERS DATED & SIGNED

Tag No.: A0454

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that Haven Behavioral Hospital of Eastern PA failed to ensure that all Physician Orders were countersigned by a practitioner within 24 hours, authenticated properly by ordering practitioner and by practitioner caring for patient.

This Facility continues to be under a Plan of Correction (POC) for regulation 482.24(c)(2)Content of Record: Orders Date & Signed from a previous survey that have been conducted. An unannounced complaint survey (9QNM11), which concluded on August 3, 2021 and POC accepted August 31, 2021. Facility POC stated the following would be completed:

1. Medical Director provided verbal communication to Medical staff on 8/12/21 reminding to check each day for orders that needs to be signed within 24 hours of the order being given. Email sent to Medical Staff 8/13/21

2. Medical Director checked each patient on 8/10/21 and ensured all orders were up to date and signed appropriately.

3. Medical Staff were provided with instructions of how to check for outstanding orders when they log into the Medication Ordering system. The medical Director will continue to monitor and review again in Next Executive Committee

4. A sample of 30 charts will be reviewed each month to ensue telephone orders are
signed within 24 hours. This will be measured until 4 consecutive months at 90 %
compliance is achieved.

5. Verbal reeducation to medical staff was completed on 8/12/21. Email reminder to
sign orders was provided 8/13/21. All charts checked for outstanding unsigned orders
8/12/21.


Findings:

On January 25, 2022 review of facility Medical Staff Rules and Regulations last approved January 2021 revealed, "Introduction: These Rules and Regulations (the "Rules and Regulations") are incorporated by reference into the Medical Staff Bylaws of Hospital. They are intended to clarify standards of medical practice and the conditions of appointment to the Medical Staff ...7 Medical Records- 7.7 All entries to the medical record must be legibly written, dated, timed and authenticated Orders - All orders for medication and/or treatment for patients admitted to the Hospital shall be present in the medical record. Orders must be complete, including the name of the Practitioner giving the order and the date, time, and justification for the order. An order shall be considered to be entered if dictated by telephone to a registered nurse or, in the case of an order for medication, either to a registered nurse or a licensed pharmacist, and signed within twenty four (24) hours. ... 7.0 Medical Records -7.14 Completion of Medical Records -All discharge summaries and other medical record documentation shall be completed within thirty (30) days following the patient's discharge. Incomplete records exceeding thirty (30) days following discharge will be considered delinquent. Disciplinary measures, as specified in the Medical Staff Bylaws, will be instituted against the Practitioner who fails to complete medical records within the specified time frame.... "Article IX Corrective Action- 4. Automatic Suspension and Expulsion.-The following conduct or events shall result in automatic suspension from Medical Staff membership and Clinical Privileges and shall not entitle the Affected Physician or Other Affected Practitioner to the Hearing and appeal rights specified in these Bylaws, unless otherwise expressly provided...1. Medical Records- Medical Staff Members must complete their patients' medical records, in accordance with all applicable Rules and Regulations and all applicable procedures of the Hospital and Medical Staff, within 15 days of each patient's discharge or within such other period as the MEC may prescribe from time to time. Medical records that the Medical Staff Member fails to complete within 15 days (or other specified time period) shall be considered delinquent. The Medical Records Department shall notify Medical Staff Members in writing of incomplete medical records nearing delinquent status. This notification shall remind the Medical Staff Member that Clinical Privileges shall be automatically suspended in the event that he does not complete the medical records within five (5) working days following receipt of notice. If the Physician fails to complete medical records after such notification, all of his Clinical Privileges shall be automatically suspended."


On January 25, 2022 review of facility policy Telephone and Verbal Orders last approved September 2021 revealed, "Procedure: Telephone and Verbal Orders / Read Back and Verification: Only telephone and verbal orders from an approved licensed independent practitioner (LIP) will be taken. Telephone and verbal orders shall be received and recorded immediately in the patient's medical record by the licensed nurse. Verbal orders are only used in an emergency situation. The order will be entered into the computerized physician order system, represented as a telephone or verbal order, and include the receiver's name and title. The prescriber shall co-sign the order within 24 hours. ... ."


A review on January 21, 2022, of MR4, MR5, MR7, MR8, MR9 and MR10, revealed they contained Orders that were not signed by the physician within 24 hours.

A review on January 21, 2022 of MR4, MR5, MR6, MR7, MR8, MR9 and MR10 revealed Orders that lacked the title of the receiver of the Orders, and failed to have practitioner authenticate.

Review of MRs 1-10 revealed verbal orders were entered during admissions for medications, treatments and ancillary orders. Additional review of MR4, MR5, MR7, and MR9 showed that verbal orders were used for additional occurrences other than on admission in each of these medical records for non-emergent medication and ancillary orders.

Interview with EMP1 confirmed verbal orders were used for admission orders and non-emergent orders in ten out of ten medical records reviewed.


On January 21, 2022 report documenting when Medical Staff Members were notified in writing of incomplete medical records nearing delinquent status was requested from EMP5. EMP5 stated there is no documentation Medical Staff Members were notified of incomplete medical records. EMP5 confirmed this report is not run under my department.

On January 21, 2022 interview conducted with EMP1 who stated facility has not assigned a Department to regularly check medical records for orders not being signed of within 24hours and then notify Medical Staff.