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Based on a review of facility documents, medical records (MR) and staff interviews (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted Governing Body Bylaws by failing to provide oversight of their Behavioral Health Unit (BHU) when the Unit combined two distinct patient populations into one Unit, resulting in patient harm in the BHU (0144), without updating the Scope of Service of the Unit (0057), and by failing to provide education to their BHU staff specific to the needs of the population being care for on the Unit (0397) as evidenced by, inadequate staffing (0392) resulting in Nursing resorting to the use of IM medications to control behaviors (0201), with the increased assistance of Security personnel (0283), which subsequently results in delayed discharge of patients with Intellectual Development Disorder (IDD) back into their community settings (0201), and also by failing to ensure adequate staff on their Medical Units and in the Laboratory (0077), resulting in inadequate monitoring of patients, as evidenced by the elopement of a telemetry monitored patient with dementia, and events related to the delay in collection and processing of Lab specimens which resulted in delay of patient care. (0286, 0309).


Cross Reference:
482.12(b) Chief Executive Officer. (0057)
The Governing Body must appoint a chief executive officer who is responsible for managing the hospital.
482.12(d)(7) Institutional Plan and Budget.(0077)
By a committee consisting of representatives of the governing body, the administrative staff, and the medical staff of the institution.

Based on a review of facility documents and staff interviews (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted Governing Body Bylaws by failing to provide oversight of their Behavioral Health Unit (BHU) when the Unit began providing services to the Intellectual Development Disorder (IDD) population without updating the Unit's Scope of Service, and by failing to provide education to staff in order to meet the needs of the change in the population served in their BHU, resulting in harm to a patient.


Findings:


Board of Trustees Bylaws of Conemaugh Memorial Medical Center, dated February 10, 2020 revealed, "... Article I-General Scope. Be it resolved that the bylaws set out below shall govern the transaction of the business and affairs of the Hospital. ... 1.1(b) Provide appropriate facilities and services to best serve the needs of patients; 1.1(c) Improve the standards of health care in the community; ... 1.1(e) Encourage educational activities relating to tendering care to the sick and injured or to the promotion of health, as may be justified by the facilities, personnel, funds, or other resources that are available; ... 6.3 Chief Executive Officer's Responsibility The authority and duties of the CEO shall include responsibility for the following: ... 6.3(d) Developing a plan of organization of the personnel and others concerned with the operation of the Hospital, including establishing and managing such non-Medical Staff departments as necessary; 6.3(e) Selecting, employing, controlling and discharging employees and developing and maintaining personnel policies and practices for the Hospital; ... 6.3(l) Serving as liaison officer and conveying all communication among Corporation, the Board, the Medical Staff, the AHP Staff and hospital personnel; ... 8.3(d) Establishing a process designed to assure that all individuals responsible for the assessment, treatment, or care of patients are competent in the following, as appropriate to the ages of the patients served: (i) The ability to obtain information and interpret information in terms of patients' needs; (ii) a knowledge of cognitive, physical and emotional growth and development in the particular age group treated; and (iii) an understanding of the range of treatment needed by the patients. 8.3(e) Providing continuing professional education, shaped primarily by the needs identified through the review and evaluation activities; ... 8.4 Documentation The Board shall consider and act upon the findings and recommendations from the required review, evaluation, and monitoring activities. All findings and recommendations shall be in writing, signed by the persons responsible for conducting the review activities, and supported and accompanied by documentation upon which the Board can take informed action. ... ."


Conemaugh Memorial Medical Center ... PolicyStat ID: 568547 ... Last Revised: March 2019 ... Plan for the Provision of Patient Care policy and procedure. "Overview: Patient Care services provided by Memorial Medical Center are based on the Mission, Vision and High Five Guiding Principles of the Organization, as well as the needs of the community served. Patient care services are organized and deployed in response to patient needs, as identified through a multidisciplinary approach. This plan outlines the organizational components integral in the provision of effective patient care. This plan has been developed using a compilation of organizational or departmental specific documents. ... B. Patient requirements and implications for staffing. C. Essential services necessary to meet the needs of its patient population. ... H. The provision of the continuum of care throughout the organization. I. Opportunities to improve processes in the design and delivery of patient care. The leadership of Memorial Medical Center takes responsibility for providing the foundation and support for planning, directing, coordinating, providing and improving helath care services. These services are based on identified patient needs and are designed to improve patient health outcomes. ... As such, patient services will be planned, coordinated, provided, delegated and supervised by professional health care providers who recognize the unique physical, cultural, emotional and spiritual needs of each person. The medical staff, registered nurses, allied health care professionals and ancillary support staff participate in inter-professional collaboration, as part of a multi-disciplinary team to achieve optimal patient outcomes. Patient services and care areas are limited to those departments that have direct contact with patients. The full scope of patient care is provided by licensed professionals who have the responsibility of patient assessment, planning and treatment. ... Patient Care Areas. Inpatient Care Units: ... Professional Patient Care Staff: Roles and Functions. The interdisciplinary commitments of all departments in the provision of patient care is demonstrated through collaborative policy/procedure development, open communication, participation in performance excellence teams, multidisciplinary care rounds, and clinical conferences. All patients can expect to receive uniform levels of care throughout Memorial Medical Center. .... D. Each patient is provided an environment which promotes social well-being. ... C. The patient is provided with a safe, comfortable environment. D. The patient's physical needs are met through appropriate patient care interventions. ... G. The patient's rights are respected and assured. ... Scope of Service. Each Department will have a defined scope of services and goals which support the operation of the organization. ... ."



Interview with EMP6 revealed that there is no current defined departmental "Scope of Services" policy and procedure for Behavioral Medicine.


Review of the Adult & Geropsych Staff Meeting minutes was completed. July & August meeting minutes revealed topics of discussion that included but not limited to: "Combine G7 & G8 for current situation-combined units ... Max is 8 Geropsych patients on the Unit at a time. ... ."

Review of documentation from EMP13 on September 17, 2020, revealed, "... In response to complaints from Nursing, the Geropsych Unit admissions were halted and we merged the two floors for better staffing along with limiting the number of geriatric patients for safety reasons. ... ."

Review of documentation from EMP6 dated October 30, 2020, at 8:14 PM revealed, "... The decision to close the Geriatric Psych Unit was made by EMP2. To place the five remaining geriatric patients on the Adult Unit was also made by EMP2. I have never had responsibility to inform the Board about anything in my role, that has been the Chief Nursing Officer. We made every attempt to keep the geriatric psych patients on one wing and several of them were ordered one to ones when indicated to maintain safety. As far as staff education for caring for IDD ... I did have 2 people come from Erie who run group homes and provided an inservice last year. ... ."

A list of staff educational trainings, orientation, required education and competencies was provided by EMP2. Only one of 13 educational requirements revealed a topic related to the care of patients with Intellectual Developmental Disabilities entitled, "Communicating with Hospitalized Individuals with an Intellectual/Development Disability ... ."

Based on a review of facility documents and interviews with staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted Governing Body Bylaws by failing to provide adequate numbers of staff in their Behavioral Health Unit, their Medical Units and in their Laboratory.

Findings:

Board of Trustees Bylaws of Conemaugh Memorial Medical Center, dated February 10, 2020 revealed, "... Article I-General Scope. Be it resolved that the bylaws set out below shall govern the transaction of the business and affairs of the Hospital. 1.1 Purpose: The purpose, goals and objectives of the Board of Trustees of Conemaugh Memorial Medical Center shall be to: 1.1(a) In cooperation with Corporation, support, manage, and furnish facilities, personnel and services; provide diagnosis, medical, surgical and hospital care, outpatient care and other hospital and medically related services ... 1.1(b) Provide appropriate facilities and services to best serve the needs of patients; 1.1(c) Improve the standards of health care in the community; ... 1.1(e) Encourage educational activities relating to tendering care to the sick and injured or to the promotion of health, as may be justified by the facilities, personnel, funds, or other resources that are available; ... 1.1(h) Provide overall institutional planning, with participation of the Medical Staff, Nursing Department, ... 6.3 Chief Executive Officer's Responsibility The authority and duties of the CEO shall include responsibility for the following: ... 6.3(d) Developing a plan of organization of the personnel and others concerned with the operation of the Hospital, including establishing and managing such non-Medical Staff departments as necessary; 6.3(e) Selecting, employing, controlling and discharging employees and developing and maintaining personnel policies and practices for the Hospital; ... 6.3(l) Serving as liaison officer and conveying all communication among Corporation, the Board, the Medical Staff, the AHP Staff and hospital personnel; ... 8.3(d) Establishing a process designed to assure that all individuals responsible for the assessment, treatment, or care of patients are competent in the following, as appropriate to the ages of the patients served: (i) The ability to obtain information and interpret information in terms of patients' needs; (ii) a knowledge of cognitive, physical and emotional growth and development in the particular age group treated; and (iii) an understanding of the range of treatment needed by the patients. ... ."




Conemaugh Memorial Medical Center ... PolicyStat ID: 568547 ... Last Revised: March 2019 ... Plan for the Provision of Patient Care policy and procedure. "Overview: Patient Care services provided by Memorial Medical Center are based on the Mission, Vision and High Five Guiding Principles of the Organization, as well as the needs of the community served. ... This plan has been linked to the organization's Strategic Planning Process and considers the following: A. Patient/Customer/Stakeholder needs, expectations, and satisfaction. B. Patient requirements and implications for staffing. C. Essential services necessary to meet the needs of its patient population. D. Planning for the provision of those essential services, either directly, or through referral or contract. E. The Organizations's ability to recruit and/or develop appropriate staff. F. Relevant information from staffing variance reports. ... The leadership of Memorial Medical Center takes responsibility for providing the foundation and support for planning, directing, coordinating, providing and improving health care services. ... F. Continuous evaluation of services provided through formalized, systematic, and ongoing process, i.e. evidence based national and state benchmarks, performance assessment and performance excellence activities, budgeting, staffing plans and input from the Patient Advisory Council. ... As such, patient services will be planned, coordinated, provided, delegated and supervised by professional health care providers who recognize the unique physical, cultural, emotional and spiritual needs of each person. The medical staff, registered nurses, allied health care professionals and ancillary support staff participate in inter-professional collaboration, as part of a multi-disciplinary team to achieve optimal patient outcomes. Patient services and care areas are limited to those departments that have direct contact with patients. The full scope of patient care is provided by licensed professionals who have the responsibility of patient assessment, planning and treatment. Patient support is provided by a variety of ancillary support staff and departments, who may not have direct contact with patients, but show support the care provided by licensed care providers. ... ."


Telephone interview with EMP20 on October 12, 2020, at 1:00 PM revealed, "We have been struggling with Phlebotomists. ... We are still having a big turnover. ... The majority of our Lab Techs work as Phlebotomists. Even some of our Managers have been working as Phlebotomists. ... Our events actually went up the weekend where we had complaints, the 25th, 26, and 27th, but then slowed down after that. There were some delays and cancelled tests. ... A lot of times, we ask the Night shift Phlebotomist to stay for morning collections. ... Administration is aware of our staffing needs. ... ."


Review of Performance Excellence Committee (PEC) meeting minutes dated February 2020, revealed more specifically that the Behavioral Health Service Line was facing staffing challenges and there has been an increase in the number of intellectually challenged patients being admitted to the Unit. No plan of action was documented.

Review of Performance Excellence Committee (PEC) meeting minutes dated May 2020, June 2020, July 2020 and August 2020. There was no documented evidence of discussion or analysis of staffing issues on the Behavioral Health Unit, M7, Good Samaritan 6 or the Laboratory Department, nor was there any documented discussion or analysis of Security Alerts related specifically to violent/aggressive patient behaviors on the Medical/Surgical and Behavioral Health Units.



EMP2 responded when queried about reporting Behavioral Health employee injuries, staff overtime and no lunch punches (too busy to take lunch break) to the Board on November 3, 2020, "... We have quarterly safety reviews and regulatory compliance updates. To my knowledge we have not shared productivity and staffing details with the Board ... ."

The Conemaugh Board Meeting Minutes and Medical Executive Committee (MEC) Meeting Minutes failed to reveal any documented discussion of staffing concerns on the Behavioral Health Units, or any other departments of the facility, or discussion regarding the cohorting of geriatric psychiatric and adult psychiatric patients, and also failed to reveal any discussion of Security Alerts, any discussion of the telemetry monitored dementia patient elopement, or any discussion related to Laboratory specimen collection and processing delays impacting patient care.

Based on a review of facility documents, medical records (MR) and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to provide care in safe setting as evidenced by failing to provide education to staff specific to the needs of the population served (0144), failed to provide adequate staffing resulting in Nursing resorting to the use of IM medications to control patient behaviors, with the increased use of Security personnel assistance (0201), and also evidenced by combining two distinct patient populations into one Unit, resulting in patient harm in the BHU, and also by failing to ensure adequate staff on their Medical Units and in the Laboratory, resulting in inadequate monitoring of patients as evidenced by the elopement of a telemetry monitored patient with dementia, and events related to the delay in collection and processing of Lab specimens (0144).




Cross Reference:
482.13(c)(2) The patient has the right to receive care in a safe setting.
482.13(f)(2)(iii) Choosing the least restrictive intervention based on an individualized assessment of the patient's medical, or behavioral status or condition.

Based on a review of facility documents, medical records (MR) and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to provide care in safe setting as evidenced by failing to protect vulnerable Geropsych patients from other adult psych patients with violent, aggressive behaviors resulting in harm to a Geropsych patient, and also by failing to ensure adequate numbers of staff on their Medical Units and in their Laboratory, resulting in inadequate monitoring of patients as evidenced by the elopement of a telemetry monitored patient with dementia, and events related to the delay in collection and processing of Lab specimens.


Findings Include:


Conemaugh Memorial Medical Center ... PolicyStat ID: 6119805 ... Policy Area: Organizational ... Patient Rights policy and procedure dated March 2019. "Statement of Policy: It is the policy of Conemaugh Health System (CHS) to respect the rights of patients during their hospitalization and to recognize that each patient is an individual with unique health care needs. Staff will provide considerate, respectful care, incorporating patient's personal values and belief systems and strive to protect each patient's dignity. ... Information regarding patient's rights and responsibilities is made available to all patients including adults and parents or guardians of neonates, children and adolescent patients at the time of admission. The Statement of Patient's Rights and Responsibilities is attached as Appendix A of this policy. Requirements: CHS assures patient rights are supported by the following: ... 4. A policy to render care and treatment appropriate to the patient's condition. ... 7. Addressing the psychosocial needs of the patient which are identified during the hospital stay and initiating appropriate referrals as necessary. ... 12. Policies and processes to ensure a patients' right to management of symptoms related to their illness, including prompt and appropriate management of pain. ... This policy is meant to provide a framework for the Conemaugh Health System philosophy of patient care and is used in conjunction with other policies to assure that patients' rights are recognized and respected. ... ."


Conemaugh Health System A Statement of the Patient's Rights [Appendix A] to above policy and procedure. "Conemaugh Health System is committed to providing quality care to all patients and to make their visit as pleasant as possible. Our concern and respect for you, our patient, is addressed in this Statement of Patient's Rights. 1. You have the right to respectful care given by skilled staff. ... 9. You have the right to quality care and high professional standards that are always kept and reviewed. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid any personal discomfort. ... ."


Conemaugh Memorial Medical Center ... PolicyStat ID: 7211456 ... Policy Area: Behavioral Medicine ... Patient Rights Mental Health policy and procedure dated November 2019. "Purpose: To ensure that care, treatment and services are provided in a way that respects and fosters dignity autonomy, positive self-regard, civil rights, and involvement of patient. Policy: 6. You have the right to receive treatment in the least restrictive setting within the facility necessary to accomplish the treatment goals. 7. You have the right to be discharged from the facility as soon as you no longer need care and treatment. 8. You have the right not to be subject to any harsh or unusual treatment. ... ."



Conemaugh Memorial Medical Center ... PolicyStat ID: 7554557 ... Policy Area: Nursing ... Remote Cardiac Monitoring: Medical/Surgical Nursing-Procedure and Responsibilities dated February 2020. "Policy: All staff caring for patients requiring remote cardiac monitoring will follow established procedures, guidelines and reponsibilities to provide a safe environment for our patients. Objectives: To provide remote cardiac monitoring on patients on ... Responsibilities: On admission/new monitor order ... Monitor orders are timed for either 24 hours, 48 hours, or indefinite. ... Indefinite orders are valid for the entirety of the patient's admission until the physician writes an order to discontinue. ... Responsibilities: The nursing unit staff ... RN reviews alarm parameters with monitor technician in order to individualize patient care. In collaboration with the monitor technician, the RN can adjust alarm parameters within approved 40-125 range. Adjusting alarm parameters less than 40 or higher than 125 requires physician notification. ... ."


Conemaugh Memorial Medical Center ... PolicyStat ID: 7273637 ... Policy Area: Nursing Central Monitor ... Remote Cardiac Monitoring Refusal Policy and Procedure dated December 2019. "Statement of Policy: The purpose of this policy is to provide guidelines for the management of patients who are refusing remote cardiac monitoring or are unable to comply with remote monitoring due to confusion or agitation. Points of Emphasis: ... For patients who are deemed unable to make decisions in regards to remote cardiac monitoring due to confusion or agitation, the following guidelines are followed: A. The RN will notify the provider that the patient is confused/agitated and is unable to comply with prescribed remote cardiac monitoring and an entry will be documented in the patient's electronic medical record. B. The patient's surrogate will be notified. For patients that are confused and agitated and unable to comply with remote cardiac monitoring, the nurse and physician will collaborate to ensure that all alternative means of cooperation have been attempted. The provider will place an order to discontinue the remote cardiac monitoring. In substitution for continuous remote cardiac monitoring, the provider may elect for nursing to perform EKGs per provider order. As the patient has been determined to not be competent to make decisions on their own behalf, the patient's surrogate should be contacted and education provided. The nurse will document the notification/education of the surrogate in the patient's electronic medical record Responsibility Nursing ... ."


MR4 revealed, "... Nursing Note ... September 14, 2020 @ 1506 ... PT1 attacked PT2 after PT2 told PT1 that it wasn't good to cheat during a card game. PT1 yelled '[----] you b..ch' at PT2, who then said 'Don't talk to me in that tone.' PT1 stood up and grabbed PT2 walker, and then beat PT2 in the face, neck and chest with walker. ... ."


MR5 revealed, "... Resident Assessment Note ... 09/14/20 @ 1442 ... Reason: Patient was assaulted with a walker ... Findings: Left frontal small hematoma measuring 3x3 cm Assessment: Patient has been attacked with a walker and patient received a strike on head. ... Plan: 1-ordered CT head, neck, chest, and abdomen 2- Cold pack to the frontal hematoma 3-Ordered Voltaren gel every 6 hrs 4-monitor conscious level closely ... ."


An interview with EMP16 on September 17, 2020, at approximately 11:15 AM revealed, "... We had an incident where a mental health patient with Intellectual Development Disorder (IDD) hit a Geropsych patient with a walker. PT2 was joking with PT1 and PT1 did not like it. It happened so quickly. ... ."

Interview with EMP3 on September 18, 2020, at approximately 9:30 AM revealed, "The mix of the two patients, being IDD and the impulsivity. ... One said something to the other and PT1 just grabbed whatever was available which was PT2 walker. ... ."

Interview with EMP14 was conducted on September 17, 2020, at approximately 10:30 AM revealed, "... I was here when PT1 hit PT2 with a walker. It happened so fast, if we had more help it may have not happened. ... ."


Interview with EMP13 on September 17, 2020 at 10:40 AM, revealed, "Staffing since the pandemic has been a problem with inability to staff appropriately at times for RNs and Mental Health Techs (MHT), on Behavioral Health Unit (BHU). The staff are all getting stressed out, and we have continued to tell Management. An RN may have a 20 patient case load. We had to discharge some patients and transfer some because we closed the Geropsych Unit. We do not have enough Techs to work on the Unit. ... There's not enough man power. ... It's an overwhelming feeling because we are short nurses and MHTs . ... Recently met with EMP23 and EMP17 when we merged the Adult psych and the Geropsych Units. ... Training the staff with Crisis Intervention and an increase with staffing would help."


MR6 "... History Of Present Illness: ... 76 y.o. ... past medical history significant for Alzheimer's dementia, ... and ... who presents for readmission to the ED for evaluation of problems related to ambulation and dizziness after eloping from the hospital earlier in the night. The patient does not remember leaving the hospital room, however patient's spouse reports that patient escaped the hospital, showed up at their house around 12 AM. ... Currently, patient complains of some mild lower extremity and back pain likely secondary to recent walk from hospital to home. ... September 20, 2020 0244 ... ."

Telephone interview with EMP25 on September 23, 2020, at 9:30 AM revealed, "... The patient presented to the ER on Friday, September 18, 2020, with dizziness, low heart rate, exhaustion, dehydration. Patient was a known wanderer. The patient's spouse was very clear about this with the ER staff and told them that patient needs watched closely ... It was Saturday into Sunday around 1:00 AM that the patient's spouse called the hospital and informed the Nurse that patient was ringing their door bell stating that they returning home from the library. The Nurse was not aware that patient was gone. ... ."

MR6 ED to Hosp-"Admission September 18, 2020 ... 1324 Physician Orders ... Cardiac monitoring: Indefinite. ... ."

MR6 Nursing Note "... September 19, 2020 0141 ... Patient's heart rate is 38-50. Notified Resident. ... Patient is very confused. ... Patient was in the bathroom and had heart monitor ripped off. ... September 20, 2020 @ 0047 ... Patient confused to place time and situation. Refused bed alarm and cardiac monitor. Becomes restless and agitated when encouraged to place both. ... ."

Facility Monitor Tech documentation dated Saturday, September 19, 2020, revealed, "... [MR6] SB 50 (37-35) Night SB 30 Refusing ... Day refusing ... ."

Facility documentation from EMP1 per EMP18 dated September 22, 2020, at 12:59 PM revealed, "... Patient was ordered a cardiac monitor, but would remove it frequently. I spoke with Monitor Tech and they have no recordings after 6 PM on September 19, 2020."

Facility documentation from EMP1 per EMP18 dated September 22, 2020, at 2:16 PM revealed, "There was no physician order to discontinue the telemetry monitor. ... ."

EMP18 confirmed that there was no documented evidence in the patient's medical record (MR6) that the spouse or physician was notified of the patient's refusal to wear the monitor.

MR6 revealed the last documented evidence of hourly rounding was at 4:18 PM, and no further documentation of any staff/patient interaction after a 9:00 PM medication administration, until the patient's spouse notified Nursing that the patient had eloped and walked home.

Interview with EMP18 on September 28, 2020, at 2:30 PM confirmed the above findings.



Telephone interview with EMP20 on October 12, 2020, at 1:00 PM revealed, "We have been struggling with Phlebotomists. ... We are still having a big turnover. ... The majority of our Lab Techs also work as Phlebotomists. Even some of our Managers have been working as Phlebotomists. ... Our events actually went up the weekend where we had complaints, the 25th, 26, and 27th, but then slowed down after that. There were some delays and cancelled tests. ... A lot of times, we ask the Night Shift Phlebotomist to stay for morning collections. ... Administration is aware of our staffing needs. ... ."

A review of random incident/events related to the Laboratory was conducted for the time period of late evening on September 25, 2020, into the morning hours on September 26, 2020, when staffing was decreased by one Phlebotomist/Technician. It was noted that four of five incidents/events were related to a delay in specimen collection or collection that did not occur, which in turn, delay meals and medications.

Review of Lab schedule dated September 22, 2020, through September 28, 2020, was conducted with EMP20 on October 12, 2020, at 1:15 PM. The review revealed a total of 21 shifts that included 5:00 AM until 1:00 PM, 1:00 PM/2:00 PM until 9:00 PM/10:00 PM and 9:00 PM/10:00 PM until 5:00 AM/6:00 AM. Of the 21 shifts, seven shifts were short one Phlebotomist or Lab Technician for all or part of the shift.

EMP20 confirmed the above findings.

Based on a review of facility documents, medical records (MR) and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to provide education and training to their Behavioral Health staff regarding the implementation of the least restrictive intervention specific to the needs of patients exhibiting aggressive, or self destructive behaviors, to assist the patient to maintain self-control and avoid escalation, as an alternative to Nurses requiring the assistance of Security Personnel to administer IM medications to control patient behaviors, the use of which subsequently results in the delayed discharge of patients with IDD back into their least restrictive community settings.


Findings Include:


Conemaugh Memorial Medical Center ... PolicyStat ID: 6119805 ... Policy Area: Organizational ... Patient Rights policy and procedure dated March 2019. "Statement of Policy: It is the policy of Conemaugh Health System (CHS) to respect the rights of patients during their hospitalization and to recognize that each patient is an individual with unique health care needs. Staff will provide considerate, respectful care, incorporating patient's personal values and belief systems and strive to protect each patient's dignity. ... Information regarding patient's rights and responsibilities is made available to all patients including adults and parents or guardians of neonates, children and adolescent patients at the time of admission. The Statement of Patient's Rights and Responsibilities is attached as Appendix A of this policy. Requirements: CHS assures patient rights are supported by the following: ... 4. A policy to render care and treatment appropriate to the patient's condition. ... 7. Addressing the psychosocial needs of the patient which are identified during the hospital stay and initiating appropriate referrals as necessary. ... 12. Policies and processes to ensure a patients' right to management of symptoms related to their illness, including prompt and appropriate management of pain. ... This policy is meant to provide a framework for the Conemaugh Health System philosophy of patient care and is used in conjunction with other policies to assure that patients' rights are recognized and respected. ... ."


Conemaugh Health System A Statement of the Patient's Rights [Appendix A] to above policy and procedure. "Conemaugh Health System is committed to providing quality care to all patients and to make their visit as pleasant as possible. Our concern and respect for you, our patient, is addressed in this Statement of Patient's Rights. 1. You have the right to respectful care given by skilled staff. ... 9. You have the right to quality care and high professional standards that are always kept and reviewed. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid any personal discomfort. ... ."


Conemaugh Memorial Medical Center ... PolicyStat ID: 7211456 ... Policy Area: Behavioral Medicine ... Patient Rights Mental Health policy and procedure dated November 2019. "Purpose: To ensure that care, treatment and services are provided in a way that respects and fosters dignity autonomy, positive self-regard, civil rights, and involvement of patient. Policy: 6. You have the right to receive treatment in the least restrictive setting within the facility necessary to accomplish the treatment goals. 7. You have the right to be discharged from the facility as soon as you no longer need care and treatment. 8. You have the right not to be subject to any harsh or unusual treatment. ... ."


Conemaugh Memorial Medical Center Policy Stat ID: 8285714 ... Last Revised 07/2020 ... Restraint for Violent Destructive Behavior Policy. Philosophy: Memorial Medical Center promotes a violence and coercion-free treatment philosophy that focuses on the prevention of emergencies that have the potential to lead to restraint and seclusion use. Conemaugh Memorial Medical Center is committed to prevent, reduce, and eliminate the use of seclusion/restraint through early implemented and intervention of high-risk behaviors or events. Restraint and Seclusion interventions are implemented only as a last resort to protect the physical safety of the patient, staff, or others when behaviors pose a risk of imminent harm to the patient, staff, or others. Non-physical interventions are the preferred method of intervention and the use of seclusion/restraint is considered to be an exception and not a standard of practice. Leadership supports clinical staffing to the levels appropriate to the needs of the patients in restraint and on the unit. ... Chemical Restraint = Drugs used as Restraint: A drug or medication when used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment for the patient's condition ... . Restraint shall not be used when less restrictive interventions would be effective. ... The use of alternative strategies, including preventative, de-escalate, and verbal intervention techniques prior to restraint and seclusion. If alternative strategies were not able to be used the rationale is documented. ... ."

Conemaugh Memorial Medical Center ... PolicyStat ID: 7538038 ... Policy Area: Environment of Care ... Security Alert policy and procedure dated January 2020. "... Statement of Policy: This policy is written to provide a safe and secure environment for all of our patients, visitors and staff. If verbal techniques by staff do not de-escalate the patient, visitor or employee behavior, a Security Alert will be announced. ... Requirements: A. The procedure will be initiated by any employee when a patient, visitor or employee displays unmanageable behavior and the employee's inability to de-escalate the situation by verbal techniques. ... If the event occurs in a Behavioral Medicine Unit, an order may be given to use seclusion room and/or restraints. ... 5. If the patient's violent behavior remains uncontrollable and a physician or designee orders physical or chemical restraints, ... ."


Review of Security documentation for the time period of February 1, 2020, through August 31, 2020 was conducted to determine frequency and volume of Security Personnel assisting BHU Nursing staff with physical holds and/or restraint application in order to administer prn medication. It was noted that there were eight Security Alerts and seven calls for Security personnel presence on the Gero Unit, and 35 Security Alerts and a 61 calls for Security's presence for the Adult Unit.


Review of 11 Security Alerts for the Adult Unit was conducted for the dates between July 26, 2020, through August 8, 2020, and September 4, 2020, through September 8, 2020. The Security Alerts involved four patients, all of whom had a diagnosis related to IDD-Intellectual and Developmental Disabilities or Autism and revealed patient behaviors that included: hitting head off of the ground, combativeness, spitting, kicking, biting, thrashing around on bed, self-induced vomiting, throwing objects, standing on chair/windowsill, attempting to elope, hitting walls, cutting self with styrofoam cup, flipping over chairs, ripping down curtains and assaultive behavior.
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These behaviors necessitated the use of Security Personnel to assist Nursing in providing patient care that included physical holds to allow for the administration of prn medication and/or application of restraints on the Adult Behavioral Health Unit.


Telephone interview with EMP7 September 24, 2020, at 12:45 PM revealed, "We are rounding up there (BHU) every hour. ... Within the last few months, there has been an increase because of a patient(s) that has been there for quite a while, ... ."


Psychiatric History and Physical for MR1 included diagnoses not limited to: Anxiety, Autism, Bipolar I Disorder and Seizures. Security documentation dated July 30, 2020, revealed that at 5:31 PM the Nursing staff was struggling to control the patient (MR1) from hitting head off of the ground. When enough staff arrived, they lifted the patient from the floor to the bed and the patient became more combative by spitting, kicking, punching, attempting to bite. The documentation revealed that the patient was restrained and medicated. Security documentation dated July 31, 2020, revealed that at 11:40 PM the staff were controlling the patient (MR1) to stop patient from biting their own fingers. The documentation revealed that after the patient was restrained and medicated with three injections, they became increasingly agitated by thrashing around on the bed so the nurse requested that the staff and officers control the patient until the patient calmed down and medication took effect. Security documentation dated August 1, 2020, revealed that at 9:28 AM the patient (MR1) was found to be in restraints due to biting and hitting self. The patient was also medicated. ... 08/01/20 2028 ... Patient was given PRN IM Haldol, Benadryl, and Ativan because patient remains restless and continues to make self vomit. Security documentation dated August 7, 2020, revealed that at 2:06 PM the patient (MR1) was throwing crayons at staff and writing on the floor, then was standing on chairs. The patient was instructed to come down, did so and was then medicated. The patient was asked to walk to their room but once there started to act out by hitting items in the room and attempting to hit staff. The documentation revealed that the staff controlled the patients arms and legs until the medications could take effect and patient calmed down.


Psychiatric History and Physical for MR2 included diagnoses not limited to: Dementia likely secondary to vascular etiology/traumatic injury with behavioral disturbance, traumatic brain injury, mood disorder secondary to TBI and impulse control disorder. Security documentation dated July 28, 2020, revealed that at 9:32 AM the patient (MR2) was being controlled by several staff members due to aggressive and assaultive behavior. The patient was medicated as a result. Security documentation dated July 30, 2020, revealed that at 9:22 AM the MR2 was being controlled by arms and legs for being combative and kicking at the staff. The patient was medicated as a result. ... 07/30/20 1107 ... Patient wandered into another patient's room and sat on top of their bed. Staff immediately assisted MR2 back to their own room at which point they became agitated and aggressive. Security called to assist with medication administration. IM Ativan administered.


Psychiatric History and Physical for MR3 included diagnoses not limited to: Autism spectrum disorder with intellectual disability requiring support, generalized anxiety disorder, adjustment disorder with mixed emotion and conduct. ... 07/26/20 1915 ... During shift change, patient stole something off of MHT then went to their room and slammed the door. Patient was confronted and refused to empty their pockets. Multiple attempts to de-escalate the patient and convince patient to show us what they had, patient refusing to cooperate. Security notified. While waiting for Security, patient decided to throw everything they possibly could, papers, crayons, bed mattress at staff. Restraints applied, and while restraining the patient, they were vulgar and profane and spit in RN's face. IM Zyprexa and Benadryl were administered.


Psychiatric History and Physical for MR4 included diagnoses not limited to: Autism spectrum disorder with intellectual disability, History of TBI, Schizoaffective disorder bipolar type, Depressive disorder unspecified, Anxiety disorder unspecified. Security documentation dated July 31, 2020, revealed that at 4:49 PM the patient (MR4) struck a nurse in the head and forearm with their fist. The documentation revealed that the patient was restrained and medicated. ... 07/31/20 1735 ... Patient became upset over not having their jersey and attempted to run away from the 1:1. Patient reports they had to hit the nurse because they are mad and frustrated. Security was called and patient was placed in 4 point restraints and was given IM Benadryl and Haldol. ... It was noted that MR4 had a 130 day stay on the BHU and was medicated for behaviors frequently.

An inquiry was made as to length of stay for patients with IDD admitted to the BHU. On November 18, 2020, EMP6 provided data that revealed length of stay was between 47 and 205 days. EMP6 revealed that placement for IDD patients is difficult as group homes often do not want the patient to return due to their violent, aggressive behaviors that require prn injections.

Interview with EMP13 on September 17, 2020 at 10:40 AM, revealed, "Staffing since the pandemic has been a problem with inability to staff appropriately at times for RNs and MHTs, on BHU. ... By nature, the agitated patients require more resources. We have been limiting admission of agitated psych patients. There are a number of group homes with IDD patients with impulse control issues, who send them to the hospital because they feel unsafe. ... They are individuals with rights. We can't always provide them with the resources that they need. When these individuals are at the group homes, their guardians know what some of their triggers are, and what helps them. When here, it's a new thing, like re-inventing the wheel for them. ... It's an overwhelming feeling because we are short nurses and MHTs . ... Recently met with EMP23 and EMP17 when we merged units. ... Training the staff with Crisis Intervention and an increase with staffing would help."

An interview was conducted with EMP6 dated October 30, 2020, at 8:14 PM revealed, "... We made every attempt to keep the geriatric patients on one wing and several of them were one to ones when indicated to maintain safety. As far as education for IDD ... I did have 2 people come from Erie who run group homes and provided in services last year. ... ."

A list of staff educational trainings, orientation, required education and competencies was provided by EMP2. Only one of 13 educational requirements revealed a topic related to caring for patients with Intellectual Developmental Disabilities entitled, "Communicating with Hospitalized Individuals with an Intellectual/Development Disability ... ."

Based on a review of facility documents and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted Performance Excellence Plan by failing to identify, analyze and implement preventative measures to ensure patient safety (0283), by failing to provide adequate staffing resources and education specific to the populations served in their BHU, Medical Units and Laboratory (0309), and by failing to adopt a Departmental Scope of Service for Behavioral Medicine (0286).


Cross Reference:
482.21(b)(2) Quality Improvement Activities
482.21(c)(2) Patient Safety, Medical Errors and Adverse Events
482.21(e) Executive Responsibilities

Based on a review of facility documents and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted Performance Excellence Plan by failing to identify, analyze and implement preventative measures to ensure patient safety.


Findings Include:


Review of the Patient Safety and Excellence and Clinical Quality Performance Excellence Program Plan, dated December 2019, revealed "... The Performance Excellence Committee's key responsibilities are to review and make appropriate recommendations on the following: Top-level, corporate commitment to performance excellence; Information flow throughout the organization; Objective measures to gauge the quality of care and services being provided such that all patients with the same health problems and care needs are receiving the same quality of care; Quality management programs and quality related policies; The degree to which the organization meets patients' expectations; ... Patient Safety and Clinical Quality Performance Excellence Program Plan ... Patient Safety/Risk Management; Safety and Emergency Preparedness ... ."


Conemaugh Memorial Medical Center ... PolicyStat ID: 4456988 ... Policy Area: Organizational-General ... Best Practices/Clinical Practice Guidelines policy and procedure dated August 2018, revealed, "... Statement of Policy: It is the policy of Memorial Medical Center to support best medical practice through utilization of benchmark data, clinical trial results, and recommendations by nationally recognized organizations. Criteria selection is focused on desired outcomes (mortality and morbidity reduction, functional status improvement, reduction in length of stay, and total cost.) ... Clinical practice guidelines provide a means to improve quality, enhance appropriate utilization of health care services, and enhance the value of healthcare services. ... ."


Conemaugh Memorial Medical Center ... PolicyStat ID: 8081014 ... Policy Area: Nursing ... Nurse Staffing Plan policy and procedure dated May 2020. "Statement of Policy: The organization recognizes it's responsibility to ensure sufficient numbers of qualified staff to meet its mission and scope of services. ... Monitoring Staffing Levels: Staffing levels are monitored by their department on a 4-hr, 8-hr, 12-hr basis to ensure an appropriate utilization of qualified resources. Variances to staffing are reviewed along with an analysis of why the variance occurred, and what actions were taken to address the variance. Managers and Directors take an active role in following their Staffing Grids and providing nursing unit coverage. ... ."


Conemaugh Memorial Medical Center ... PolicyStat ID: 8121464 ... Policy Area: Environment of Care-Security ... Security Management Plan, policy and procedure dated May 2020. "Security Management Plan 2020. I. Scope: The Security Management Plan describes the methods of providing security for people, equipment and other material through risk assessment and management for DLP Conemaugh Memorial Medical Center. ... B. The assessment of risks to identify potential problems is central to reducing crime, injury and other incidents. C. Analysis of security incidents provides information to predict and prevent crime, injury, and other incidents. D. Training hospital staff is critical to ensuring their performance. ... IV. Organization & Responsibility. A. The Board of Trustees receives regular reports of the activities of the Security Program from the multidisciplinary improvement team, the Environment of Care (EOC) Committee, which is responsible for the Physical Environment issues. They review reports and, as appropriate, communicate concerns about identified issues and regulatory compliance. ... D. Department heads are responsible for ... They are also responsible for the investigation of incidents occurring in their departments. ... The Security Manager works with leadership to identify security sensitive areas by utilizing risk assessments and analysis of incident reports. ... The following areas are currently designated as security sensitive areas: 1. Behavioral Medicine (vulnerable patients) ... Following any security incident, a written 'Security Incident Report' will be filed by the Security Manager managing the incident. The appropriate Security Supervisor, if necessary will review the Report. ... A summary of these Reports will be furnished to the Environment of Care Committee on a regular basis. ... ."


Review of Performance Excellence Committee (PEC) meeting minutes dated February 2020, revealed more specifically that the Behavioral Health Service Line was facing staffing challenges and there has been an increase in the number of intellectually challenged patients. No plan of action was documented.


Review of Performance Excellence Committee (PEC) meeting minutes dated March 18, 2020, revealed more specifically the "Environment of Safety Quarterly Report" revealed that there was no documented evidence of discussion or analysis of the "Security Alerts" related to Security personnel being called to assist Nursing with patient violent behaviors on the Behavioral Health Unit.

Review of Performance Excellence Committee (PEC) meeting minutes dated May 2020, June 2020, July 2020 and August 2020. There was no documented evidence of discussion or analysis of staffing issues on the Behavioral Health Unit, M7, Good Samaritan 6 or the Laboratory Department, nor was there any documented discussion or analysis of Security Alerts related specifically to violent/aggressive patient behaviors on the Medical/Surgical and Behavioral Health Units.


Review of Environment of Care Committee Meeting Minutes dated November 26, 2019, December 23, 2019, February 27, 2020, April 23, 2020 and June 25, 2020, revealed that there was no documented evidence in the meeting minutes related to the discussion of Security Alerts related specifically to Security personnel being called to assist Nursing with patient violent behaviors on the Behavioral Health Unit or Medical Units.

Interview with EMP24 on October 2, 2020, revealed that the Security Alerts related specifically to violent/aggressive patient behaviors on the Medical/Surgical and Behavioral Health Units are not documented in the Environment of Care Committee meeting minutes.


EMP2 responded when queried about reporting employee injuries, staff overtime and "no lunch punches" (too busy to take a lunch break) to the Board on November 3, 2020, "... We have quarterly safety reviews and regulatory compliance updates. To my knowledge we have not shared productivity and staffing details with the Board ... ."

Review of Conemaugh Memorial Medical Center Board of Trustees meeting minutes dated March 25, 2020, May 25, 2020, June 24, 2020, July 24, 2020, and draft meeting minutes dated August 26, 2020, was conducted as well as a review of "Medical Executive Committee" meeting minutes dated January 20, 2020, through August 17, 2020.

The Conemaugh Board Meeting Minutes and Medical Executive Committee (MEC) Meeting Minutes failed to reveal any documented discussion of staffing concerns on the Behavioral Health Units, or any other departments of the facility, or discussion regarding the the cohorting of geriatric and adult patients, and also failed to reveal any discussion of Security Alerts, any discussion of the telemetry monitored dementia patient elopement, or any discussion related to Laboratory specimen collection and processing delays impacting patient care.

Based on a review of facility documents and interview with staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted Performance Excellence Plan by failing to identify, analyze and implement preventative measures to ensure patient safety on their Behavioral Health Unit, Medical Units and in their Laboratory.


Findings Include:


Review of the Patient Safety and Excellence and Clinical Quality Performance Excellence Program Plan, dated December 2019, revealed "... The Board is responsible to set the direction for performance excellence ... actively plans and prioritizes quality and patient safety activities ... Performance Excellence Committee of the Board: Although the ultimate responsibility and authority for organization-wide performance excellence rests with the Board of Trustees, the Board delegates oversight responsibility and authority to the Performance Excellence Committee (PEC) of the Board. This Committee is composed ... shall serve as the Board's working committee on all matters pertaining to performance excellence. ... The Performance Excellence Committee's key responsibilities are to review and make appropriate recommendations on the following: Top-level, corporate commitment to performance excellence; Information flow throughout the organization; Objective measures to gauge the quality of care and services being provided such that all patients with the same health problems and care needs are receiving the same quality of care; Quality management programs and quality related policies; The degree to which the organization meets patients' expectations; ... Patient Safety and Clinical Quality Performance Excellence Program Plan ... Patient Safety/Risk Management; Safety and Emergency Preparedness ... ."



Conemaugh Memorial Medical Center ... PolicyStat ID: 568547 ... Last Revised: March 2019 ... Plan for the Provision of Patient Care policy and procedure. "Overview: Patient Care services provided by Memorial Medical Center are based on the Mission, Vision and High Five Guiding Principles of the Organization, as well as the needs of the community served. Patient care services are organized and deployed in response to patient needs, as identified through a multidisciplinary approach. ... This plan has been linked to the organization's Strategic Planning Process and considers the following: A. Patient/Customer/Stakeholder needs, expectations, and satisfaction. B. Patient requirements and implications for staffing. C. Essential services necessary to meet the needs of its patient population. ... H. The provision of the continuum of care throughout the organization. I. Opportunities to improve processes in the design and delivery of patient care. The leadership of Memorial Medical Center takes responsibility for providing the foundation and support for planning, directing, coordinating, providing and improving health care services. These services are based on identified patient needs and are designed to improve patient health outcomes. ... Professional Patient Care Staff: Roles and Functions ... All patients can expect to receive uniform levels of care throughout Memorial Medical Center. .... The standards of patient care at Memorial Medical Center are as follows: A. Each patient's health status is assessed. The collection of data is systematic and continuous, serving as a basis for determining the health care needs and delivery of care. B. Each patient has a plan of care. A multi-disciplinary approach is utilized, as appropriate, to promote continuity of care. C. Physical needs of the patient are addressed through interventions to achieve an optimal health outcome. D. Each patient is provided an environment which promotes social well-being. E. Patient education and discharge planning are provided to the patient and/or support system. Patient Care Goals: Patient care goals are outcome expectations for each standard of care. In essence, the patient care goals define the expected care to be received by each patient. The patient care goals at Memorial Medical Center are: A. Early recognition of patient condition will promote identification of patient care needs. B. Patient care interventions complement the patient's plan of care. C. The patient is provided with a safe, comfortable environment. D. The patient's physical needs are met through appropriate patient care interventions. E. The patient's psychological stress is minimized and coping abilities are enhanced. F. The patient and/or support system is provided with information and/or resources to provide ongoing care to the best of their ability. G. The patient's rights are respected and assured. H. The patient and/or support system will be satisfied with the care provided. ... Scope of Service. Each Department will have a defined scope of services and goals which support the operation of the organization. ... ."

Conemaugh Memorial Medical Center ... PolicyStat ID: 8121464 ... Policy Area: Environment of Care-Security ... Security Management Plan, policy and procedure dated May 2020. "Security Management Plan 2020. I. Scope: The Security Management Plan describes the methods of providing security for people, equipment and other material through risk assessment and management for DLP Conemaugh Memorial Medical Center. ... B. The assessment of risks to identify potential problems is central to reducing crime, injury and other incidents. C. Analysis of security incidents provides information to predict and prevent crime, injury, and other incidents. D. Training hospital staff is critical to ensuring their performance. ... IV. Organization & Responsibility. A. The Board of Trustees receives regular reports of the activities of the Security Program from the multidisciplinary improvement team, the Environment of Care (EOC) Committee, which is responsible for the Physical Environment issues. They review reports and, as appropriate, communicate concerns about identified issues and regulatory compliance. ... D. Department heads are responsible for ... They are also responsible for the investigation of incidents occurring in their departments. ... The Security Manager works with leadership to identify security sensitive areas by utilizing risk assessments and analysis of incident reports. ... The following areas are currently designated as security sensitive areas: 1. Behavioral Medicine (vulnerable patients) ... Following any security incident, a written 'Security Incident Report' will be filed by the Security Manager managing the incident. The appropriate Security Supervisor, if necessary will review the Report. ... A summary of these Reports will be furnished to the Environment of Care Committee on a regular basis. ... ."


Review of Performance Excellence Committee (PEC) meeting minutes dated February 2020, revealed more specifically that the Behavioral Health Service Line was facing staffing challenges and there has been an increase in the number of intellectually challenged patients. No plan of action was documented.

Review of Performance Excellence Committee (PEC) meeting minutes dated March 18, 2020, revealed more specifically the "Environment of Safety Quarterly Report" revealed that there was no documented evidence of discussion or analysis of the "Security Alerts" related to Security personnel being called to assist Nursing with patient violent behaviors on the Behavioral Health Unit.

Review of Performance Excellence Committee (PEC) meeting minutes dated May 2020, June 2020, July 2020 and August 2020. There was no documented evidence of discussion or analysis of staffing issues on the Behavioral Health Unit, M7, Good Samaritan 6 or the Laboratory Department, nor was there any documented discussion or analysis of Security Alerts related specifically to violent/aggressive patient behaviors on the Medical/Surgical and Behavioral Health Units.



Review of Environment of Care Committee Meeting Minutes dated November 26, 2019, December 23, 2019, February 27, 2020, April 23, 2020 and June 25, 2020, revealed that there was no documented evidence in the meeting minutes related to the discussion of Security Alerts related specifically to Security personnel being called to assist Nursing with patient violent behaviors on the Behavioral Health Unit or Medical Units.

Interview with EMP6 revealed that there is no current defined departmental "Scope of Services" policy and procedure for Behavioral Medicine.

Interview with EMP24 on October 2, 2020, revealed that the Security Alerts related specifically to violent/aggressive patient behaviors on the Medical/Surgical and Behavioral Health Units are not documented in the Environment of Care Committee meeting minutes.

Review of Employee Health Office documentation revealed 10 Behavioral Health or Security staff injuries dated August 19, 2020, through October 31, 2020.


EMP2 responded when queried about reporting employee injuries, staff overtime and no lunch punches to the Board on November 3, 2020, "... We have quarterly safety reviews and regulatory compliance updates. To my knowledge we have not shared productivity and staffing details with the Board ... ."

Review of Conemaugh Memorial Medical Center Board of Trustees meeting minutes dated March 25, 2020, May 25, 2020, June 24, 2020, July 24, 2020, and draft meeting minutes dated August 26, 2020, was conducted as well as a review of "Medical Executive Committee" meeting minutes dated January 20, 2020, through August 17, 2020.

The Conemaugh Board Meeting Minutes and Medical Executive Committee (MEC) Meeting Minutes failed to reveal any documented discussion of staffing concerns on the Behavioral Health Units, or any other departments of the facility, or discussion regarding the cohorting of geriatric and adult patients, and also failed to reveal any discussion of Security Alerts, any discussion of the telemetry monitored dementia patient elopement, or any discussion related to Laboratory specimen collection and processing delays impacting patient care.

Based on a review of facility documents and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted Performance Excellence Plan by failing to provide adequate staffing resources to meet the specific needs of the patients on their BHU, Medical Units and in the Laboratory, by failing to address opportunities to improve quality of care and patient safety.


Findings Include:


Board of Trustees Bylaws of Conemaugh Memorial Medical Center dated February 10, 2020 revealed, "... Article I-General Scope. Be it resolved that the bylaws set out below shall govern the transaction of the business and affairs of the Hospital. 1.1 Purpose: The purpose, goals and objectives of the Board of Trustees of Conemaugh Memorial Medical Center shall be to: ... 1.1(i) Maintain a commitment to continued comprehensive quality assurance and quality improvement in all aspects of health care provided by the Hospital in cooperation with the Medical Staff, CEO and hospital. ... Article III-Membership & Meetings of the Board of Trustees ... 3.11(d) Establishing, maintaining and supporting, through the CEO and the Medical Staff and its designated committees a comprehensive, hospital-wide program for quality assessment and improvement; receiving reports of quality improvement information on a regular basis from the Medical Staff, and assuring that all aspects of the program are performed appropriately and that administrative assistance is available to the Medical Staff; 3.11(e) In consultation with the MEC, the Corporation and the CEO, formulating programs for efficient delivery of care, ... ."




Conemaugh Memorial Medical Center ... PolicyStat ID: 8081014 ... Policy Area: Nursing ... Nurse Staffing Plan policy and procedure dated May 2020. "Statement of Policy: The organization recognizes it's responsibility to ensure sufficient numbers of qualified staff to meet its mission and scope of services. To accomplish this, each department follows their designated Staffing Grid. ... Monitoring Staffing Levels: Staffing levels are monitored by their department on a 4-hr, 8-hr, 12-hr basis to ensure an appropriate utilization of qualified resources. Variances to staffing are reviewed along with an analysis of why the variance occurred, and what actions were taken to address the variance. Managers and Directors take an active role in following their Staffing Grids and providing nursing unit coverage. ... ."


Review of Performance Excellence Committee (PEC) meeting minutes dated February 2020, revealed more specifically that the Behavioral Health Service Line was facing staffing challenges and there has been an increase in the number of intellectually challenged patients. No plan of action was documented.


Review of Performance Excellence Committee (PEC) meeting minutes dated March 18, 2020, revealed more specifically the "Environment of Safety Quarterly Report" revealed that there was no documented evidence of discussion or analysis of the "Security Alerts" related to Security personnel being called to assist Nursing with patient violent behaviors on the Behavioral Health Unit.

Review of Performance Excellence Committee (PEC) meeting minutes dated May 2020, June 2020, July 2020 and August 2020. There was no documented evidence of discussion or analysis of staffing issues on the Behavioral Health Unit, M7, Good Samaritan 6 or the Laboratory Department, nor was there any documented discussion or analysis of Security Alerts related specifically to violent/aggressive patient behaviors on the Medical/Surgical and Behavioral Health Units.


Review of Environment of Care Committee Meeting Minutes dated November 26, 2019, December 23, 2019, February 27, 2020, April 23, 2020 and June 25, 2020, revealed that there was no documented evidence in the meeting minutes related to the discussion of Security Alerts related specifically to Security personnel being called to assist Nursing with patient violent behaviors on the Behavioral Health Unit or Medical Units.

Interview with EMP24 on October 2, 2020, revealed that the Security Alerts related specifically to violent/aggressive patient behaviors on the Medical/Surgical and Behavioral Health Units are not documented in the Environment of Care Committee meeting minutes.


EMP2 responded when queried about reporting employee injuries, staff overtime and no lunch punches to the Board on November 3, 2020, "... We have quarterly safety reviews and regulatory compliance updates. To my knowledge we have not shared productivity and staffing details with the Board ... ."

Review of Conemaugh Memorial Medical Center Board of Trustees meeting minutes dated March 25, 2020, May 25, 2020, June 24, 2020, July 24, 2020, and draft meeting minutes dated August 26, 2020, was conducted as well as a review of "Medical Executive Committee" meeting minutes dated January 20, 2020, through August 17, 2020.

The Conemaugh Board Meeting Minutes and Medical Executive Committee (MEC) Meeting Minutes failed to reveal any documented discussion of staffing concerns on the Behavioral Health Units, or any other departments of the facility, or discussion regarding the cohorting of geriatric and adult patients, and also failed to reveal any discussion of Security Alerts, any discussion of the telemetry monitored dementia patient elopement, or any discussion related to Laboratory specimen collection and processing delays impacting patient care.

Based on a review of facility documents, medical records (MR) and interview with staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted staffing grid/matrix on their Behavioral Health Unit (BHU), and on their Medical/Surgical Units (Good Samaritan 6 and M7)(0392), as evidenced by failing to conduct one to one observation checks as per a physician order in four of seven Behavioral Health medical records (MR9, MR11, MR13 and MR18) and to conduct hourly rounding as per Nursing policy in two of two medical records (MR6 and MR31). and failed to ensure that Nursing personnel had the appropriate education and specialized qualifications to provide nursing care to the populations served on their BHU. (0397)


Cross Reference:
482.23(b) Staffing and delivery of care
482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff availalble.

Based on a review of facility documents, medical records (MR) and interview with staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted staffing grid/matrix on their Behavioral Health Unit (BHU), and on their Medical/Surgical Units (Good Samaritan 6 and M7), as evidenced by failing to conduct one to one observation checks as per a physician order in four of seven Behavioral Health medical records (MR9, MR11, MR13 and MR18) and to conduct hourly rounding as per Nursing policy in two of two medical records (MR6 and MR31).



Findings Include:


Conemaugh Memorial Medical Center ... PolicyStat ID: 8081014 ... Policy Area: Nursing ... Nurse Staffing Plan policy and procedure dated May 2020. "Statement of Policy: The organization recognizes it's responsibility to ensure sufficient numbers of qualified staff to meet its mission and scope of services. To accomplish this, each department follows their designated Staffing Grid. ... Flexing/Floating of Staff: Each Patient Care Unit will be responsible to assess their staffing needs by following the Staffing Grid specific to their Nursing Unit. ... Monitoring Staffing Levels: Staffing levels are monitored by their department on a 4-hr, 8-hr, 12-hr basis to ensure an appropriate utilization of qualified resources. Variances to staffing are reviewed along with an analysis of why the variance occurred, and what actions were taken to address the variance. Managers and Directors take an active role in following their Staffing Grids and providing nursing unit coverage. ... A registered nurse supervises and evaluates the nursing care of each patient. ... Floats and 1:1 observations assistant's mealtime schedule is on the assignment sheet and coverage for patient assignments for mealtime is written on the assignment sheet. Assignment sheets are currently retained. ... The Nursing Assistant/Patient Care Assisstant/Clinical Associate/Mental Health Technician is assigned to assist with care of patients under the supervision [sic] the licensed Registered Nurse. Patient care assignments are established to provide continuity of care and promote Patient Safety."


Review of the policy entitled "Patient Observation 1:1 Policy Stat ID 7624492," last revised February 2020, revealed, "... 1:1 Patient Observation is a safety measure to provide a 1:1 staff/patient ratio for the patient found by clinical assessment to be exhibiting behavior that may be harmful/risky to self and including, but not limited to others. The 1:1 staff member stays with and observes the patient continually. A Physician order is required to discontinue 1:1 observation for patients demonstrating harmful behavior or may be at risk to self and others ... Discontinuation: A Physician/Provider order is required for discontinuation of the 1:1 observation for destructive behavior. ... Documentation occurs every 15 minutes for patients on 1:1 observation ... Points of Emphasis: 1. The decision to utilize nursing unit staff will be determined by the Clinical Coordinator or Nursing AD in the absence of the Nurse Manager, to maintain a safe patient environment ... 1:1 staff must have continual visual observation of the patient at all times, including the use of the bathroom, physician rounding, and off the unit for testing. Patient's head and hands must be visible at all times. *Arm's length of the patient at all times while observing patients who are on high suicide risk precautions. 4. 1:1 staff must maintain their full attention on the patient, interacting with them as appropriate ... 8. 1:1 observation is required for patients who are in violent & destructive behavioral restraints ... The primary outcome of 1:1 observation is to prevent a patient from injuring him/herself utilizing the least restrictive method that is effective, while maintaining the patient's dignity, rights and well-being ... ."


Conemaugh Memorial Medical Center ... PolicyStat ID: 7624699 ... Policy Area: Nursing ... Hourly Rounding--Intentional Rounding policy and procedure dated February 2020. "Statement of Policy: Hourly rounding is a methodical method of proactive nursing in respect to promotion of safety and maintenance of patient/staff communication. ... Staff Requirements: Staff address the following during each hourly rounding to promote safety and fall prevention, while meeting the patients needs and expectations. Offer bathroom visit, or when necessary a bedpan or urinal to meet toileting needs. Ask the patient if they are having pain ... Ask patient if they need anything, complete their requests. Ask patient/family if they have any questions or concerns, and get the answers for them. Address emotional needs while being empathetic and professional, ... Turning-re-positioning patients at risk of skin injury (turning is scheduled on ODD hours) At meal times be certain ... Nurses will check IV site, tubing, pump, drains, lines, SCD, Safety Efforts, Make certain call bell, phone, water container, tissues are within reach ... the patient bed is in the lowest wheels locked, and 2 side rails are up. Reinforce to patients at high risk for falling and their ... Remind the patient to call the Nursing staff via the call bell for assistance. Patients at risk for fall: check to be certain ... Instruct Patients that have IV's, lines, and cables connected to them, to call for the Nursing staff via the call bell for assistance as each is a tripping hazard. Make certain the floor is clear of cords and dry Prior to leaving room, ask the patient if there is anything else you can do for them. Remind the patient that you or another member of the nursing staff (from on the board in the room) will be checking on them in an hour. Documentation: Hourly Rounding and actions taken are documented during the staff's shift. ... ."


Review of Adult & Gero Staff Meeting, July & August meeting minutes revealed topics of discussion that included but not limited to: "Combine G7 & G8 for current situation-combined units ... Max is 8 Gero patients on the unit at a time. ... ."

Review of documentation from EMP13 on September 17, 2020, revealed, "... In response to complaints from Nursing, the Geriatric Psych Unit admissions were halted and we merged the two floors for better staffing along with limiting the number of geriatric patients for safety reasons. ... ."


A review of staffing/assignment schedules for the Gero Unit dated July 26, 2020, through August 8, 2020, revealed a total of 10 of 42 shifts that the Gero Unit was not staffed for part or all of the shift with an MHT to provide coverage consistent with the requirement of the staffing/census matrix.


A review of staffing/assignment schedules for the Adult Unit dated August 1, 2020, through August 8, 2020, revealed a total of one of 24 shifts that the Adult Unit was not staffed with an MHT to provide coverage consistent with the requirement of the staffing/census matrix.


A review of staffing/assignment schedules for the Adult Unit (Geropsych Unit temporarily suspending admissions as of August 10, 2020) dated September 4, 2020, through September 8, 2020, revealed a total of two of 15 shifts that the Adult Unit was not staffed for part of the shift with an MHT to provide coverage consistent with the requirement of the staffing/census matrix.

EMP3 confirmed the above findings.

An event related to a staffing issue was submitted on August 2, 2020 at 8:00 AM, therefore a review of the Gero Nursing Staff schedules/assignments for August 2, 2020, was conducted with EMP3 on September 28, 2020, at 2:00 PM. It was able to be confirmed that the Gero Unit was short an MHT on 7-3, from 11:00 AM until 3:00 PM, the entire 3-11 shift and the entire 11-7 shift.

An interview with EMP8 at approximately 9:10 AM on September 17, 2020, revealed, "There is just too much to do. ... The geriatric psych patients and the adult psych patients are mixed together. They do not adjust staffing for acuity. Today we are short 4 people at 3 PM. I have been mandated multiple times. ... I don't feel we have adequate staff. ... Sometimes I am scared to come to work. I have seen interviews being done. New staff come and go, no one stays."

An interview with EMP9 at approximately 9:20 AM on September 17, 2020 revealed, "I was last mandated Tuesday, two days ago. ... The geriatric psych and adult psych patients egg each other on, so we need more staff to watch them. Sometimes we don't get breaks or lunch. When you do go to break or lunch and come back you are behind for the rest of the shift. There is only a skeleton crew at night. ... We just need more help. Combining the units was not good. ... ."
An interview with EMP10 at approximately 9:25 AM on September 17, 2020 revealed, "I was last mandated last week. They tell us to ask for help if we can't get done, but it doesn't work. If there are discharges and we could use the extra help, they still flex people off. We all feel unsafe. ... The 3-11 and 11-7 shifts are more risky. Security staff comes from up the street but it takes them a while. ... The elderly on this floor do not get the care they need. ... ."
An interview with EMP11 at approximately 9:40 AM on September 17, 2020, revealed, "Our staffing fluctuates and right now it is bad. Yesterday I was assigned 11 patients and I did not feel safe. I had to do back charting, I should not have had 11 patients by myself. ... I feel pressured and uneasy. I have had several injuries, the beginning of this year I was assaulted and had to be monitored for a concussion. Even before the combination of the two Units, we were being pulled to the Geropsych floor. ... I don't have staff at 3:00 and at 7:00, I am short 4 people. People are resigning. When the census goes down, we are told to call staff off, but sometimes we could still use them to help. There is no plan for acuity. ... I feel unsafe more often than not and for the patients. With less staff it is easier for the patients to escalate. Security staff response time is five to ten minutes depending upon the Security person. It can also be as long as 15-20 minutes, one night it was greater than 22 minutes for a Code Green response. ... Our census has varied on adult from 14 to 18 to 22 to 24 and now 21 since the geriatric floor closed. We have been short staffed this whole time. I don't want to see the Unit close. I just want it to be safe. We have highly aggressive patients and long-term patients. ... ."

An interview with EMP12 on September 17, 2020, at approximately 10:00 AM revealed, "... There are times we are short staffed, but it is what it is. ... I have been hit by patients more in the past two years than ever before. We get more intellectually disabled (IDD) patients now. Our program is not set up for this, and we don't have the training to deal with them. Maybe one IDD patient would be OK, but we keep getting more. Combining these patients with the Geropsych patients is not good. ... It has been more unsafe for the past two years. If we had more staff it would be safer. ... We have had an increase in staff injuries, but I think that is due to the population of patients. We are getting mandated more frequently for the last few months. Not everyone fills out the staffing forms, they are just too busy. ... We need more staff, more appropriate places for IDD patients to get care before the violence will go down. I was assaulted yesterday by an ID patient, when I redirected them they tried to bite me and twisted my wrist. ... ."

Eleven of 20 shifts on Good Samaritan 6 (Medical Unit) dated September 28, 2020, through October 2, 2020, failed to meet their staffing matrix for Nurse Aide requirements by one Nurse Aid.

EMP19 confirmed the above findings, "... Everyday there are staffing needs through the hospital. ... ."


Review of M7 staffing assignments/census and staffing matrix dated September 20, 2020, through September 29, 2020, revealed eight of 20 shifts failed to meet their staffing matrix for Nurse Aide requirements by one Nurse Aide, and one of 20 shifts by two Nurse Aids.


Further review of the above RN schedules/assignments for the Behavioral Health Units, Good Samaritan 6 and M7 revealed that without the frequent use of overtime or use of Charge Nurses, Clinical Coordinators, Nurse Educators and/or Nurse Managers who take on a patient assignment or patient care duties, the Units would not have been able to provide staffing consistent with the requirement of our staffing/census matrix.

EMP21 confirmed the above findings.


A sample of medical records of patients who were ordered to be on a one to one observation and/or 15 minute checks in the Emergency Department and subsequently admitted to the BHU were selected and reviewed. It was noted that the one to one and/or 15 minute checks were not being continued once the patient arrived on the BHU and there was a delay in obtaining a physician order to discontinue the orders. (MR9, MR11, MR13 and MR18)

EMP3 confirmed that medical records (MR) failed to reveal a physician order to discontinue the patient's one to one in four of seven medical records (MR9, MR11, MR13 and MR18).


MR31 Progress Notes at September 24, 2020 @ 0725 ... Patient with increased shortness of breath and pain. ... According to the patient, they reported to the nurses who responded after an hour and a half ... ."

MR31 Hourly Patient Rounds nursing documentation dated September 22, 2020, beginning at 5:00 PM through September 26, 2020, 9:00 AM was reviewed. There was no documented evidence of hourly rounding for 38 of 86 instances.

Review of facility documentation from EMP21 on October 15, 2020, at 11:57 AM confirmed the above findings and stated, "... The hourly rounding documentation was very poor. It was not completed every hour throughout the patient stay. ... I would say that it is typical that hourly rounds are not completed routinely."


MR6 Hourly Patient Rounds nursing documentation completed on the patient (MR6) beginning September 18, 2020, at 11:06 PM through September 19, 2020, at 4:18 PM was reviewed. There was no documented evidence of hourly rounding for 8 of 18 instances. There was no documented evidence of hourly rounding after 4:18 PM through the hours leading up to and including the patient's elopement from the the unit.


EMP18 on September 28, 2020, at 2:30 PM confirmed the above findings.

Based on a review of facility documents and staff interviews (EMP), it was determined that Conemaugh Memorial Medical Center failed to provide appropriate education to their Behavioral Health Unit (BHU) staff in order to be able to meet the complexity of their patients care needs, after the facility increased the number of intellectually developmental delayed (IDD) patients being admitted to the Unit, without changing the Scope of Service, and then combined two distinct patient populations into one Unit, resulting in patient harm in the BHU.


Findings:


Conemaugh Memorial Medical Center ... PolicyStat ID: 8081014 ... Policy Area: Nursing ... Nurse Staffing Plan policy and procedure dated May 2020. "Statement of Policy: The organization recognizes it's responsibility to ensure sufficient numbers of qualified staff to meet its mission and scope of services. To accomplish this, each department follows their designated Staffing Grid. ... Assignments will be adjusted and made according to the reassigned nurse's current skillset/competency level. ... Assignment of Patient Care: Nursing assignments for the provision of patient care is consistent with the qualifications of the staff and safely meet the nursing care needs of the patient. A registered nurse supervises and evaluates the nursing care of each patient. ... The Nursing Assistant/Patient Care Assisstant/Clinical Associate/Mental Health Technician is assigned to assist with care of patients under the supervision [sic] the licensed Registered Nurse. Patient care assignments are established to provide continuity of care and promote Patient Safety."


Conemaugh Memorial Medical Center ... PolicyStat ID: 7450466 ... Policy Area: Behavioral Medicine ... Admission Criteria policy and procedure dated January 2020. "Policy: Intake and Admission. Admission Criteria: Admission to an inpatient psychiatric is indicated for patients ages 12 and above who have ICD-10 diagnosis, and in addition, meet the severity of illness and intensity of service criteria (at least one from each) listed here. The decision for admission rests with the psychiatrist. ... Admission to the Adult Unit is considered for patients age 18 through 59. ... Admission to the Geriatric Unit is considered for patients age 60 and above. Exceptions to age guidelines are approved by the admitting psychiatrist in advance and are based on assessment of individual patient need. Procedure A. Severity of Illness ... B. Exclusion Criteria The physician evaluates each case on an individual basis. 1. Patients with a substantiated diagnosis of dementia with no acute behavioral change or no known psychiatric disorder and no expectation for a positive response to treatment. ... ."

Interview with EMP6 revealed that there is no current defined departmental "Scope of Services" policy and procedure for Behavioral Medicine.


Review of Adult & Gero Staff Meeting, July & August 2020 meeting minutes revealed topics of discussion that included but not limited to: "Combine G7 & G8 for current situation-combined units ... Max is 8 Gero patients on the unit at a time. ... ."

Review of documentation from EMP13 on September 17, 2020, revealed, "... In response to complaints from Nursing, the Geriatric Unit admissions were halted and we merged the two floors for better staffing along with limiting the number of geriatric patients for safety reasons. ... ."

Review of documentation from EMP6 dated October 30, 2020, at 8:14 PM revealed, "... The decision to close the geriatric psych unit was made by EMP2. To place the 5 remaining geriatric patients on the adult unit was made by EMP2, I have never had responsibility to inform the Board about anything in my role. It has been the Chief Nursing Officer. We made every attempt to keep the geriatric patients on one wing and several of them were ordered one to ones when indicated to maintain safety. As far as education for staff as to care for the increased numbers of patients with IDD ... I did have 2 people come from Erie who run group homes and provided an inservice last year. ... ."

A list of staff educational trainings, orientation, required education and competencies was provided by EMP2. Only one of 13 educational requirements revealed a topic related to patients with Intellectual Developmental Disabilities entitled, "Communicating with Hospitalized Individuals with an Intellectual/Development Disability ... ."


An interview with EMP8 at approximately 9:10 AM on September 17, 2020, revealed, "There is just too much to do. ... The geriatric patients and the adult patients are mixed together. They do not adjust staffing for acuity. Today we are short 4 people at 3 PM. I have been mandated multiple times. ... I don't feel we have adequate staff. ... Sometimes I am scared to come to work. I have seen interviews being done. New staff come and go, no one stays."
An interview with EMP9 at approximately 9:20 AM on September 17, 2020 revealed, "I was last mandated Tuesday, two days ago. ... The geriatric psych and adult psych patients egg each other on, so we need more staff to watch them. ... There is only a skeleton crew at night. ... We just need more help. Combining the units was not good. ... ."

An interview with EMP10 at approximately 9:25 AM on September 17, 2020 revealed, "I was last mandated last week. ... We all feel unsafe. ... The 3-11 and 11-7 shifts are more risky. Security staff comes from up the street but it takes them a while. ... The elderly on this floor do not get the care they need. ... ."

An interview with EMP11 at approximately 9:40 AM on September 17, 2020, revealed, "Our staffing fluctuates and right now it is bad. ... I feel pressured and uneasy. I have had several injuries, the beginning of this year I was assaulted and had to be monitored for a concussion. Even before the combination of the two Units, we were being pulled to the Geropsych floor. ... There is no plan for acuity. ... I feel unsafe more often than not and for the patients. With less staff it is easier for the patients to escalate. Security staff response time is five to ten minutes depending upon the Security person. It can also be as long as 15-20 minutes, one night it was greater than 22 minutes for a Code Green response. ... We have been short staffed this whole time. I don't want to see the Unit close. I just want it to be safe. We have highly aggressive patients and long-term patients. ... ."

An interview with EMP12 on September 17, 2020, at approximately 10:00 AM revealed, "... There are times we are short staffed, ... I have been hit by patients more in the past two years than ever before. We get more intellectually disabled (IDD) patients now. Our program is not set up to take care of them, and we don't have the training to deal with them. Maybe one IDD patient would be OK, but we keep getting more. Combining these patients with the Gero patients is not good. ... It has been more unsafe for the past two years. If we had more staff it would be safer. ... We have had an increase in staff injuries, but I think that is due to the population of patients. ... We need more staff, more appropriate places for IDD patients to get care before the violence will go down. I was assaulted yesterday by an IDD patient, when I redirected them they tried to bite me and twisted my wrist. ... ."


EMP19 confirmed the above findings, "... Everyday there are staffing needs through the hospital. ... ."