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Based on a review of facility documents, it was determined that Conemaugh Memorial Medical Center failed to follow adopted Board of Trustee Bylaws, by failing to ensure that signatures required signifying that the Bylaws are the duly adopted Board of Trustee Bylaws of the Hospital, were obtained prior to adopting, by failing to adopt Governing Body Bylaws consistent with the facility's adopted Medical Staff Bylaws definition of a practitioner and by failing to review and evaluate activities to include complaints/grievances to ensure the preservation and improvement of the overall quality and efficiency of patient care in the Hospital.



Findings include:

Board of Trustee Bylaws of Conemaugh Memorial Medical Center, dated August 2019 revealed "... 'Board of Trustees' or 'Board' means the local governing body appointed by the Corporation exercising those prerogatives and authorities herein and subject to the limitations delineated herein ... 'Corporation' means DLP Conemaugh Memorial Medical Center, LLC ... 'Practitioner' means a physician, psychologist or dentist who has been granted clinical privileges as the Hospital ... Article I ... 1.1 Purpose ... 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 to sick, injured, or disabled persons ... Provide appropriate facilities and services to best serve the needs of patients ... 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 personnel ... Article III ... Conflict of Interest ... Annually, on or before December 1st, each Board member shall file with the Board Secretary a written statement describing each actual or proposed relationship of that member, whether economic or otherwise, other than the member's status as a Board member and/or a member of the community, which in any way and to what degree may impact on the finances or operations of the Hospital or its staff, or the Hospital's relationship to the community ... 3.11 Responsibilities ... The responsibilities and obligations of the Board shall include: 3.11 (a) Assuming responsibility for Medical Staff oversight and quality care evaluation as described in Section 7.2 and 8.1 if these bylaws ... 3.11 (d) Establishing, maintaining and supporting, through the CEO and 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 ... ; 3.11 (e) In consultation with the MEC, the Corporation and the CEO, formulating programs for efficient delivery of care, compliance with applicable law (Medicare regulations and other applicable regulations) and development, review and revision of policies and procedures ... 3.11 (p) In cooperation with the CEO and other hospital employees, ... ; 3.11 (q) Conducting an annual evaluation of its own activities and performance; ... 3.11 (s) Establishing mechanisms to assure that all patients with the same health care problem are receiving the same level of care in the Hospital; 3.11 (t) Designating particular individuals or departments responsible for evaluating and monitoring quality of care in particular patient services, and fostering communication between such individuals or departments through establishing timeframes for discussion of these issues ... 3.11 (y) Assuming responsibility for the effective operation of the grievance process, which process the Board hereby delegates to the Patient Relations Department to be handled in accordance with Board approved policies, which policies shall include, at minimum, a requirement that quarterly summaries/reports be submitted to the Board through the Performance Excellence Committee (committee of the Board) ... Article V ... 5.4 Performance Excellence Committee. The Performance Excellence Committee shall serve as the Board's working committee on all matters pertaining to quality, making recommendations to the full Board. ... committee's responsibilities include reviewing and making recommendations on the following: corporate commitment to quality (advocate and champions); objective measure to gauge the quality of care and services being provided such that all patients with the same health problems are receiving the same level of care; risk management; quality management programs; ... licensure and related regulatory survey findings; quality-related policies; Quality Assurance and Utilization's Management Plans; education programs on quality; continuing education for Board; and the Medical Center's education programs ... At least semi-annually, the committee shall meet with the Chief of the Medical Staff to discuss matters including, but not limited to, the scope and complexity of hospital services offered, specific patient populations served by the hospital, and any issues of patient safety and quality of care ... Article VI ... 6.2 ... The Board of Trustees shall provided to Corporation an annual evaluation of the CEO's performance ... 6.3 ... The authority and duties of the CEO shall include responsibility for the following: 6.3 (a) Carrying out all policies as established by Corporation; 6.3 (b) Establishing, reviewing, and where appropriate, adjusting charges within the framework of policies established by Corporation ... 6.3 (m) Being responsible for assuring that the Hospital is in conformity with the requirements of planning, regulatory and inspecting agencies; reviewing, advising and acting promptly upon the reports of such agencies ... Article VII ... 7.2 Medical Staff Governance. The Board shall adopt bylaws and rules and regulations establishing the organization and government of the Medical Staff. The bylaws and rules and regulations shall be developed by the Medical Staff, but shall be effective only upon approval by the Board of the Corporation. ... The Medical Staff shall review and revise all Medical Staff Rules and Regulations, and, as applicable, departmental policies and procedures, when warranted, provided that such review shall occur at least very two (2) years. The Medical Staff shall recommend changes in such policies and procedures for approval by the Board and the Corporation ... Article VIII ... 8.1. Board responsibility for the Quality of Professional Services. After considering the recommendations of the Medical Staff and the other health care professionals providing patient care services, the Board shall implement specific review and evaluation activities to assess, preserve and improve the overall quality and efficiency of patient care in the Hospital. The Board, through the CEO, shall provide whatever administrative assistance is reasonable necessary to support and facilitate activities contributing to continuous quality assessment and improvement ... Article XI-Review, Amendment & Replacement. These bylaws shall be reviewed by the Board and Corporation as needed, but at least every two (2) years, and shall be dated to indicate the time of the last review. These bylaws may be amended by affirmative vote of two-thirds majority of the members of the Board, providing a full presentation of such proposed amendment shall have been established in the notice of meeting, and provided the amendments are approved in writing by Corporation. Corporation reserves the right to amend or replace these bylaws as necessary for the operation of the Hospital in the event of a change in circumstances or emergency so dictating. Corporation thereafter promptly will consult with the Board on permanent amendments to these bylaws (if any) necessary to meet the change of conditions, policy, or continuing emergency. Article XII-Adoption & Execution. These Bylaws shall not be effective until they have been approved by the Corporation. The signatures set forth below signify that the foregoing Bylaws are the duly adopted Board of Trustees Bylaws of the Hospital ... ."

Surveyor was provided with Board of Trustee Bylaws of Conemaugh Memorial Medical Center, dated October 2017, which stated "... Definitions ... 'Board of Trustees' or 'Board' means the local governing body appointed by the Corporation exercising those prerogatives and authorities specified herein and subject to the limitations delineated herein ... 'Corporation' means DLP Conemaugh Memorial Medical Center, LLC ... 'Practitioner' means a physician, psychologist or dentist who has been granted clinical privileges at the Hospital ... Article I ... 1.1 Purpose. The purposes, 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; ... 3.11 Responsibilities ... The responsibilities and obligations of the Board shall include: 3.11 (a) Assuming responsibility for Medical oversight and quality care evaluation as described in Section 7.2 and 8.1 of these bylaws ... 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, ... 3.11 (s) Establishing mechanisms to assure that all patients with the same health care problem are receiving the same level of care in the Hospital; ... 3.11 (y) Assuming responsibility for the effective operation of the grievance process, which process the Board hereby delegates to the Patient Relations Department to be handled in accordance with Board approved policies,which policies shall include, at minimum, a requirement that quarterly summaries/reports be submitted to the Board through the Performance Excellence Committee (committee of the Board) ... Article V ... 5.4 Performance Excellence Committee. The Performance Excellence Committee shall serve as the Board's working committee on all matters pertaining to quality, making recommendations to the full Board. ... Matters addressed in the Committee shall be reported to the Board. ... The CEO shall have the authority, and be held responsible for administering the Hospital in all of its activities, subject only to such policies as may be adopted and such orders as may be issued by Corporation ... 6.3 ... The authority and duties of the CEO shall include responsibility for the following: 6.3 (a) Carrying out all policies as established by Corporation ... 6.3 (m) Being responsible for assuring that the Hospital is in conformity with the requirements of planning, regulatory and inspecting agencies; reviewing, advising and acting promptly upon the reports of such agencies ... Article VII ... 7.2 Medical Staff Governance. The Board shall adopt bylaws and rules and regulations establishing the organization and government of the Medical Staff. The bylaws and rules and regulations shall be developed by the Medical Staff, but shall be effective only upon approval by the Board and the Corporation ... The Medical Staff shall review and revise all Medical Staff Rules and Regulations, and, as applicable, departmental policies and procedures, when warranted, provided that such review shall occur at least every two (2) years. The Medical Staff shall recommend changes in such policies and procedures for approval by the Board and the Corporation ... Article VIII ... 8.1 Board Responsibility for the quality of professional services. ... the Board shall implement specific review and evaluation activities to assess, preserve and improve the overall quality and efficiency of patient care in the Hospital. ... Article XI-Review, Amendment & Replacement. These bylaws shall be reviewed by the Board and Corporation as needed, but at least every two (2) years, and shall be dated to indicate the time of the last review. ... Corporation reserves the right to amend or replace these bylaws as necessary for the operation of the Hospital in the event of a change in circumstances or emergency so dictating. Corporation thereafter promptly will consult with the Board on permanent amendments to the these bylaws (if any) necessary to meet the change of conditions, policy, or continuing emergency ... Article XII-Adoption & Execution. These Bylaws shall not be effective until they have been approved by the Corporation. The signatures set forth below signify that the foregoing Bylaws are duly adopted Board of Trustees Bylaws of the Hospital ... ." Signature, dated October 24, 2017, was present on the line indicating Chair of Board, Signature, dated October 24, 2017, was present on the line indicating Officer, and Signature, dated March 14, 2018, was present on the line indicating Legal counsel for Corporation.


Board of Trustee Bylaws of Conemaugh Memorial Medical Center, dated August 2019, revealed "... 'Board of Trustees' or 'Board' means the local governing body appointed by the Corporation exercising those prerogatives and authorities herein and subject to the limitations delineated herein ... 'Corporation' means DLP Conemaugh Memorial Medical Center, LLC ... 'Practitioner' means a physician, psychologist or dentist who has been granted clinical privileges as the Hospital ... ."

Board of Trustee Bylaws of Conemaugh Memorial Medical Center, dated October 2017, revealed stated "... Definitions ... 'Practitioner' means a physician, psychologist or dentist who has been granted clinical privileges at the Hospital ... ."

Review of Medical Staff Bylaws, dated Board approved on April 23, 2019, and Medical Staff approved on May 29, 2019, revealed "... Definitions ... 'Practitioner' means a physician dentist or podiatrist who has been granted clinical privileges at the Hospital ... ."


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 in collaboration with the Medical Staff and senior management. Leadership, inclusive of Medical Staff Leadership, 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. ...PEC shall serve as the Board's working committee on all matters pertaining to performance excellence. It will be the vehicle to enhance trust and communication among the Board, corporate officer team, Medical Staff, Allied Health Staff and employees on quality-related matters by providing a candid and confidential forum for discussion. 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; ... Accreditation, licensure and related regulatory survey findings; Patient Safety and Clinical Quality Performance Excellence Program Plan ... Patient Safety/Risk Management; Safety and Emergency Preparedness ... ."



Conemaugh Memorial Medical Center ... PolicyStat ID: 7089299 ... Last Reviewed: 10/2019 ... Patient/Customer Complaint/Grievance Statement of Policy: "To ensure patients/families/customers the right to present complaints and grievances and in order to identify opportunities to improve in service excellence and promote positive outcomes, it is the policy of Memorial Medical Center to provide a prompt and appropriate response to any complaints or grievances voiced by its customers. ... Data of the type of complaint/grievances and other pertinent information will be provided to the Ideal Patient Experience Steering Committee for use in identifying opportunities for improvement. ... ."



1. Surveyor requested a current copy of the facility's Governing Body Bylaws.

The facility provided surveyor with Board of Trustee Bylaws dated August 2019. During review, it was noted that the final page entitled "Article XII-Adoption & Execution", stated "These Bylaws shall not be effective until they have been approved by the Corporation. The signatures set forth below signify that the foregoing Bylaws are the duly adopted Board of Trustees Bylaws of the Hospital." It was noted that signature lines were available for Conemaugh Memorial Medical Center Board of Trustees, Chair of the Board, DLP Conemaugh Memorial Medical Center, CDL, Officer, and and a notation of "Approved as to Form", Legal Counsel for Corporation." All signature lines were noted to be blank.

Surveyors received an updated signature page, and during a telephone interview on January 27, 2020, at approximately 11:40AM, with EMP21, it was revealed and noted that the Chairman of the Board signed the bylaws on August 27, 2019, and EMP21 stated that the reason for the delay in the signature of the line identified as "officer", was that the document was hung up in the "cue." It was noted that signatures of the officer and legal counsel for the corporation were noted to be dated January 17, 2020. EMP21 continued by stating that the Bylaws dated August 2019, were effective since the local Board approved (August 27, 2019).


2. During review of the above Board of Trustee Bylaws, it was noted that the Bylaws defined a practitioner as a physician, psychologist or dentist who has been granted clinical privileges at the Hospital.


3. Facility Complaint/Grievance documentation for MR21 revealed that a family member of the patient contacted the facility with a concern that they allowed the patient to leave the Emergency Department alone, unaccompanied by a responsible adult and/or arrangement for transportation. The family member also reported that the patient has dementia, was a resident of a local Nursing facility, wore an ankle guard due to history of wandering, was examined and discharged and subsequently recognized by a community member as the patient was wandering in the area outside the facility.

Facility Complaint/Grievance for MR20 revealed that a family member contacted the facility with concern that the patient presented to the Emergency Department by EMS after falling in a parking lot at post dialysis, that they were not notified that the patient was there, and that the patient was evaluated and discharged alone, unaccompanied by a responsible adult and/or arrangement for transportation. The family member also stated that the following morning they were notified by Security that the patient was found in the hospital parking garage in someone else's vehicle. They believe the patient spent the night wandering in the parking garage.


4. The above Complaint/Grievances (MR20 and MR21) were reviewed in the presence of the Survey Team, EMP21 and EMP6 on January 10, 2020 at approximately 2:45 PM. EMP21 stated that was EMP21 was not aware of the happenings that occurred or that grievances were received for MR20 or MR21.

5. Review of Board meeting minutes dated October 22, 2019, revealed a review of the Patient Grievance Dashboard.
EMP6 was queried on January 24, 2020, to confirm if any discussion of Complaint/Grievances (MR20 and MR21) was documented in Patient/Safety Committee, Performance Excellence Committee (PEC), or Board of Trustees Committee meeting minutes. EMP6 responded electronically on Janaury 24, 2020, at 12:06 PM, "Not specifically-our quarterly report outs on complaints and grievances (at PE Steering and PEC are numeric only ... ."

Based on a review of facility documents, medical records (MR) and staff interviews (EMP) it was determined that Conemaugh Memorial Medical Center failed to provide care in a safe setting by failing to provide 1:1 monitoring for patients identified at high risk for suicide as per doctor order, failed to follow their adopted policy on monitoring patients at risk for suicide, failed to minimize the risk for self-harm by permitting patients identified as high risk for suicide to remain in a public waiting area where staff could not immediately intervene if necessary (A-0144) in seven of 20 medical records (MR29, MR30, MR37, MR38 MR39, MR40 and MR52), and failed to follow their adopted policies by failing to ensure that the patient's condition or symptoms warranted the use of restraints in 12 of 12 medical records (MR6, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, and MR18) and by failing to apply the restraints as per the physician order in one of 12 medical records (MR6). (A-0187), and failed to follow their adopted policy to ensure the safe application of restraints and by failing to provide continuous monitoring of a patient in four point restraints, in one of one medical record (MR23). (A-0194)



Findings:

A Statement of the Patient's Rights 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 high quality care and professional standards that are always kept and reviewed. ... 15. You have the right to be free from any form of restraints (both physical/drug) that is not medically necessary. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid personal discomfort. ... ."


Conemaugh Memorial Medical Center ... PolicyStat ID: 6119805 ... Policy Area: Organizational-Clinical ... 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 personal values and belief systems and strive to protect each patient's dignity. ... Requirements: ... 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. ... ."

Attachment to the Patient Rights policy revealed, "A Statement of the Patient's Rights 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 high quality care and professional standards that are always kept and reviewed. ... 15. You have the right to be free from any form of restraints (both physical/drug) that is not medically necessary. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid personal discomfort. ... ."



Review of the policy entitled Suicide Risk Assessment/Suicide Precautions, dated October 2019, revealed "... Scope: Effective September 23rd. 2019. To provide for the appropriate level of screening and assessment for patients who are being treated for behavioral health conditions and those who are identified as high risk for suicide ... Developing a plan of care for patients with suicidal ideation ... Procedure: The approach to the care of the suicidal patient is multidisciplinary. Patients age 10 years and older who are being treated for behavioral health conditions and those who are identified as high risk for suicide using the SAFE-T Protocol with Columbia-Suicide Severity Rating Scale (C-SSRS)-Recent will be completed within the following settings/services: Department of Emergency Medicine (DEM). ... Direct admit to the Hospital. ... A follow up assessment ... will be completed Q 12 hours until the patient answers no to all questions for 24 hours ... The result of the SAFE-T Protocol with C-SSRS-Recent will determine the level of risk along with corresponding monitoring and interventions required to maintain patient safety. The results of the screen and recommended risk level will be communicated to the physician who will order the appropriate risk level which will determine the interventions and monitoring necessary to maintain patient safety ... When a patient is determined to be at risk for suicide through screening, regardless of the level of risk, the patient's safety is maintained by the following ... Implement observation process using the Patient Observation Documentation for the appropriate level of risk identified. 5. The patient's environment is secured using the Environment of Care Room Checklist at a minimum of Q 12 hours. 6. The nursing staff notifies the patient's physician of the need for suicide precautions as soon as possible following implementation. Based on clinical findings, the physician may elect to consult Psychiatry. 7. Once initiated, only a licensed independent practitioner may discontinue or reduce the level of suicide precautions/close observation ... Recommended interventions based on level or risk as assessed ... 3. Moderate Risk : Implement all of the interventions for low risk patients, as well as: Remove personal belongings that pose a safety issue (shoe laces, belts, etc.). Conduct 15 minute safety checks using Patient Observation Documentation. Observe/document every 15 minutes using the Patient Observation Documentation. Complete family/visitor education. The Registered Nurse will stay with the patient during medication administration to ensure patient has taken all medications and is not stockpiling medications for future use. The Registered Nurse will report any changes in patient's behavior and /or mood to the physician. Update Plan of Care. Patient is accompanied by staff for any off Unit activities. 4. High Risk: Implement all of the interventions for low and moderate risk patients as well as: Initiate continuous 1:1 (Within arm's length of the patient). Observe/document every 15 minutes using the Patient Observation Documentation. The patient is restricted to the Unit. For any medically necessary transport to other departments ... the patient will have 1 staff member accompany at all times. ... Performance Improvement: Suicide risk reduction strategies are evaluated as part of the overall hospital performance improvement plan and are reported to the Performance Excellence Steering Committee and Performance Excellence Committee on a quarterly basis. Evaluation of screening, assessment, and management of at-risk patient is performed ... ."


Review of the policy entitled Patient Observation 1:1, dated January 2019, 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 ... 1:1 staff member's first initial and full last name will be documented on the Unit's assignment sheet along with their shift time frame, assigned lunch break, and spectra-link number ... 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. Within 5 feet of the patient at all times while observing patients who are on moderate suicide risk precautions, and those patients being observed for exhibiting harmful/risky behavior. 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 ... 1:1 observation is required for patients who are in violent & destructive behavioral restraints ... ."


Conemaugh Memorial Medical Center ... PolicyStat ID: 4864600 ... Last Revised: April 2019 ... Policy Area: Nursing ... Restraint Non Violent Policy. Statement of Policy: Memorial Medical Center is committed to reducing restraint use, and striving to eliminate use. Non-physical interventions will be instituted with all effort to prevent situations that may lead to restraint use. The decision to use restraints is based on a through individual assessments of the patient by the Registered Nurse, at the time of a specific safety need and after less intrusive measures has been ineffective to protect the patient from harm. When a non-violent restraint is needed the restraint will be used as short of a time as necessary. During the use of a restraint, the patient's rights, dignity and well being will be protected and the patient will be treated with respect. A restraint in any form will never be used for coercion, discipline, convenience or retaliation by staff. Point of Emphasis: 1. Types of Restraints for a non-violent acute medical/surgical patient: approved for use at MMC: Wrist and Ankle Soft Restraints: up to three limbs only-At least 1 limb is to be free at all times. ... 2. Non-Violent Restraint Physician order is electronically ordered by the Provider, appropriate orders checked, date, timed, signed. ... 4. The use of a non-violent restraint requires clinical justification and is a therapeutic intervention to prevent the patient from, pulling out a medical device or otherwise injuring himself. ... 6. When restraints are first placed on the patient, a full assessment is performed by the RN and documented electronically. Evaluate for possible physiological causes, and mental status. Notify physican when the assessment discovers potential causes that may warrant further treatment or tests. ... 8. The patient will be re-assessed for discontinuation or continue need of the restraint at a minimum of every two hours. ... 11. Least restrictive non-violent restraints are used: Example: a mitt restraint is less restrictive than a wrist restraint. ... Discontinuing Restraints: The length of time spent in restraints is dependent upon their re-assessment need for the restraints. Restraints use must be discontinued as soon as possible. ... Document Care: Document under flow sheets; restraints (N/V). Complete and document all listed points of assessment and care. Document alternatives to restraints attempted. ... ."



Conemaugh Memorial Medical Center Policy Stat ID: 59888480 ... Last Reviewed: 02/2019 ... 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. Diagnoses, co-occurring conditions, prior treatment, acuity levels, age, and developmental functioning of patients are all considered when making staffing adjustments. All patients have a right to free from restraint and/or seclusion, of any form, that is imposed as a means of coercion, discipline, convenience, or retaliation by staff. The dignity and privacy of patients will be preserved to the greatest extent during the implementation and monitoring of these interventions. In addition, the use of seclusion/restraint is not based on the patient's history of seclusion/restraint or history of dangerous behavior. Purpose: To establish guidelines for the safe, effective use of seclusion and/or restraint in accordance with the Department of Health (DOH), CMS, ... To ensure the protection of the patient's rights, dignity, physical, and psychological well being of individuals requiring restraint and/or seclusion. Definitions: Restraint/Hold is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Violent & Destructive Restraint is the restriction of patient movement for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. Seclusion is the involuntary confinement of a person alone in a room or an area where the person is physically prevented from leaving. ... Seclusion may only be used for the management of violent or self-destructive behavior. ... Continuous Observation: Face-to-face in-person monitoring. ... Qualified Registered Nurse: is a licensed nurse qualified by experience, training, and competency in the use of restraint and seclusion. Provider Orders: 1. Restraint shall be ordered by a provider, physician or LIP primarily responsible for the patient's ongoing care authorized by the medical staff. ... 4. The order shall specify the method of restraint and/or seclusion to be used, (Indications for the restraint may be documented in nursing or progress notes.) Types of Violent and Destructive behavior Restraints -Chemical restraint (describe exactly) - 4 Side Rails - Physical Hold - Seclusion (open, locked) - Twice as tough x 4 -locked- blue (smaller) = Wrists; Red (large) = ankles - Remember: when applying 4-point restraints - you must use twice as tuff locked. - (Do not use soft restraints when applying 4-point restraints, use Twice as Tough locked restraint.) 5. The attending physician/provider must be contacted as soon as possible if restraint or seclusion is not ordered. Applying restraints denotes a change in patient's condition. Points of Emphasis: All patients are treated with dignity and respect, in a physical and psychological environment that supports their rights and well-being. Restraints are applied after assessment of the patient's needs, with ongoing assessment to encourage the removal of restraints or seclusion at the earliest moment in time. ... Restraint and seclusion are used only when there is an immediate risk to patient, a staff member, or other physical safety. The following must be documented in the record. ... Continuous, in-person one to one observation: Trained staff members monitor patients in restraint Violent and Destructive Behavior or seclusion and document in the electronic record every 15 minutes. - Monitoring of patients in restraint or seclusion for Violent & Destructive Behavior is done through continuous in-person 1:1 observation by a competent staff member. ... ."

Review of the Patient Safety Plan, dated June 2019, revealed "... Memorial Medical Center is committed to providing a safe environment for its patients, employees, physicians, students, volunteers, and visitors. It is the responsibility of each employee, physician, student, and volunteer to promote safety and prevent injury ... ."


1. MR29 was reviewed and revealed the patient presented to Conemaugh Memorial ED for suicidal ideation, assessed for high suicide risk, and was ordered 1:1 observation on January 3, 2020. MR29 failed to reveal any documented evidence that 1:1 observation for this patient occurred.

2. MR30 was reviewed and revealed the patient presented to Conemaugh Memorial ED for mood swings, suicidal ideation and cutting left arm on January 3, 2020, at 9:48 PM. The patient was assessed as a high suicide risk. The patient was triaged and then returned to the public Waiting Room at this time. The patient was placed in an ED cubicle on January 4, 2020 at 1:45 AM. The patient was placed on 15-minute checks at 1:30 AM and continued 15-minute checks until January 4, 2020, at 2:45 AM. At 2:45 AM the patient was ordered 1:1 observation. The patient remained in 1:1 observation until 5:30 AM. At 5:30 AM on January 4, 2020, the patient was on 15-minute checks until 6:15 AM. From 6:15 AM until 8:00AM on January 4, 2020, there is no documented evidence in MR30 of any behavioral checks. At 8:00 AM on January 4, 2020, the patient was placed in 1:1 observation and remained in 1:1 observation with appropriate documentation of behavioral checks until discharge from the Emergency Department at 2:09 PM on January 4, 2020. MR30 failed to reveal documented evidence of a follow-up/re-assessment after 12 hours.

3. MR37 was reviewed and revealed the patient presented to Conemaugh Memorial ED for depression and suicidal ideation on January 6, 2020, at 6:59 PM. The patient was assessed as a high risk for suicide at 6:59 PM and was ordered and placed on 1:1 observation at 7:00 PM. Initial documentation of 1:1 observation was authenticated at 7:30 EMP1 every 15 minutes, consistently until 10:00 PM. The patient was then admitted to a medical inpatient unit.

4. MR38 was reviewed and revealed the patient presented to Conemaugh Memorial ED for superficial cuts to left arm and active suicidal thoughts on January 6, 2020, at 10:08 PM. The patient was assessed as a high risk for suicidal thoughts at 10:10 PM and was ordered and placed on 1:1 observation at 10:30 PM. Initial documentation of 1:1 observation was authenticated at 10:30 PM by EMP12 every 15 minutes, consistently until 11:15 PM, then documentation of 1:1 observation was authenticated at 10:30 PM by EMP1 every 15 minutes, consistently until 1:45 AM on January 7, 2020. 1:1 observation was continued until 7:00 AM, discontinued at 7:29 AM and the patient was then monitored every 15 minutes until discharged via EMS at 8:55 AM.

5. MR39 was reviewed and revealed the patient presented to Conemaugh Memorial ED for suicidal ideations and cuts to wrists with thumb tack on January 6, 2020, at 2:31 PM. The patient was assessed as a moderate suicide risk at 2:19 PM and at a low suicide risk at 2:46 PM. There was no physician order to initiate any behavioral checks, however, documented evidence revealed 1:1 observation began at 8:30 PM on January 6, 2020, as authenticated by EMP1 every 15 minutes, consistently until 1:45 AM January 7, 2020. 1:1 observation documentation continued until 6:45 AM and then the patient was monitored every 15 minutes until discharged via EMS at 9:02 AM. MR39 failed to reveal documented evidence of a follow-up/re-assessment after 12 hours.

6. Further review of MR37 and MR39 revealed documented evidence that EMP1 was monitoring a 1:1 (MR37) while simultaneously monitoring another patient as a 1:1 (MR39) during the hours of 8:30 PM until 10:00 PM.
Further review of MR38 and MR39 revealed documented evidence that EMP1 was monitoring a 1:1 (MR38) while simultaneously monitoring another patient as a 1:1 (MR39) during the hours of 10:30 PM until 1:45 AM.

7. MR40 was reviewed and revealed the patient was seen for suicidal ideation on August 25, 2019, at 3:29 PM. The patient was assessed as a "Level of Risk: 1:1 Continuous Observation" at 3:28 PM and was ordered 1:1 observation on August 25, 2019, at 4:51 PM. Initial documentation of 1:1 observation began at 4:22 PM through 1:00 AM on August 26, 2019. MR40 revealed documented evidence beginning 1:00 AM that the 1:1 was no longer available, patient was in sight of the Nursing Station, curtain was open and 15 minutes checks would be performed until 6:45 PM when the patient was transferred to a tertiary facility. MR40 revealed documented evidence of a follow-up/re-assessment at 11:40 PM, at 5:58 AM on August 26, 2019, at 8:03 AM, and at 12:45 PM.

8. Interview with EMP5 on January 10, 2020, at approximately 11:30 AM and January 24, 2020, at 12:53 PM confirmed the above findings.


9. Review of MR52 revealed, "Clinical Note ... 09/14/19 ... 0910 ... Patient became verbally abusive to other patients and staff, yelling 'shut up you ...' repeatedly. Attempted to redirect patient and patient hit writer and then began kicking at another staff member. Called Security and placed patient in locked seclusion. Patient remains agitated and threatening to staff. Placed on 1:1 observation and will continue to monitor. ... 0930 ... Patient continued to be in locked seclusion, yelling, swearing, and threatening staff. Patient then began punching the window repeatedly and became more and more agitated with attempted redirection. Patient was placed in four point restraints and medicated with PRN Ativan and Benadryl. ... 1127... Patient had been in twice as tough restraints. Patient pulled both arms loose and right foot. Patient fell out of bed while left foot remained in restraints. Left foot was immediately released. Pt was lifted from floor by staff and placed back in bed. ... ."

Continued review of MR52 revealed, "... 09/15/19 1649 ... Department of Behavioral Medicine Psychiatric Progress Note ... Patient while in seclusion room, pulled both arm loose and one leg loose and fell out of bed. ... ."

MR52 revealed "Consult to Trauma Surgery ... 09/15/19 1257 ... Patient ... was recently discharged from the Trauma Service with left anterior 5-7 rib fractures, T12 compression fracture and left 5th phalanx fracture that had to be placed in 4 point restraints this morning. When nursing returned, they found the patient with half of their body on the floor and left leg still restrained to the bed. ... ."

MR52 revealed restraint and 1:1 observation checks beginning at 8:45 AM on September 15, 2019, and continuing until 10:45 AM. The patient's behavior was documented as "agitated" consistently while in restraints. Documentation then revealed that the patient was off the Unit from 11:00 AM until 12:15 PM with documentation of 1:1 observation checks restarted at 12:30 PM.

10. Telephone interview with EMP20 on January 23, 2020, at 3:50 PM revealed that the patient was assigned an MHT to do the 1:1 observation and the actual RN overseeing the care of the patient was called away for an admission. EMP20 stated that another RN came to the patient's room and found the patient restrained by the left ankle only. EMP20 was queried why the MHT didn't notify the RN of the patient's behavior and stated that the MHT was not actually paying attention to the patient. EMP20 also stated that this same MHT applied the restraints incorrectly on the patient, that they are color coded and were on the wrong extremities.

11. Telephone interview with EMP23 on January 24, 2020, revealed, "The MHT was outside of the patient's room due to their aggression. Anytime patients are restrained, they are on a 1:1 automatically and staff are to be within arms length of the patient. The MHT had their eyes off of the patient for a few minutes when another RN saw the patient was off of the bed. ... ."

12. Telephone interview with EMP24 on January 27, 2020, at approximatley 1:45 PM revealed, "... I got pulled from ... Unit to do the 1:1. I sat in front of the door with my computer. I noticed that the patient had the wrong restraints on. Ankle restraints were on the wrists and the wrists were on the ankles. I told the nurse and Security, they said it should be fine. I took my eyes off of the patient for a couple of seconds to document. ... The patient only had one leg restraint on when I turned around."


13. Review of medical record (MR6) was conducted to ascertain appropriate use of restraints. The physician order was written on April 9, 2019 at 6:32 AM, for "Non-violent or Non-Self Destructive Restraint ... Priority: Routine... Physical Restraint: Mitts - Soft Mitts Left Hand. Restraint reason: To prevent from removing vital equipment or interruption in therapies ... ." During a review of the nursing documentation it was noted that the soft mitts were applied to both the right and left hands.

During an interview with EMP11 on October 22, 2019, at approximately 11:00 AM, it was confirmed that the nursing documentation failed to reveal documented behaviors to warrant restraint use.


14. Review of medical record (MR8) was conducted to ascertain appropriate use of restraints. The physician order was written on April 13, 2019 at 12:06 AM, for "Non-violent or Non-Self Destructive Restraint ... Priority: Routine ... Physical Restraint: Soft Limb Restraints (One limb must be free at all times) : Left Arm. Restraint reason: To prevent from removing vital equipment or interruption in therapies." During a review of the nursing documentation it was noted that the patient's right upper extremity was contracted and the left upper arm was weak. It was also documented that only one restraint was applied to the Left Wrist.

During an interview with EMP11 on October 22, 2019, at approximately 11:00 AM, it was confirmed that the nursing documentation failed to reveal documented behaviors to warrant restraint use.

15. Additional review of medical records (MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17 and MR18) specific to restraint usage in the ICU/CCU was conducted. Each medical record revealed documented evidence that all patients were intubated while in restraints. Each medical record revealed that the majority of time the patients were intubated the "Behavior Events" were documented as pulling at oxygen tubing, pulling at NG/OG tube, pulling off cardiac wires and pulling at breathing tube, with corresponding "Visual Checks" documented as lethargic and subdued. Each medical record also revealed that restraints were continued regardless of the patient's status being documented as lethargic and subdued.



16. Following the review of restraint medical record (MR9) with EMP10 and EMP3 on January 7, 2020, at approximately 11:45 AM, interview with EMP3 revealed, "The only choices that the electronic medical record allows you to pick are 'Alert' and 'Lethargic.'"

Interview with EMP10 revealed, "I doubt very much that you will find any annotated nursing notes related to level of consciousness in any of the records."

Both EMP3 and EMP10 stated that there are several levels of consciousness that could describe a patient, but only two are available in EPIC (the electronic medical record).


17. Review of Critical Care Committee meeting minutes dated June 2019-October 2019, revealed restraint usage between 16%-48% on 6 Rose.


18. Review of MR23 revealed, "Clinical Note ... 09/14/19 ... 0910 ... Patient became verbally abusive to other patients and staff, yelling 'shut up you ...' repeatedly. Attempted to redirect patient and patient hit writer and then began kicking at another staff member. Called Security and placed patient in locked seclusion. Patient remains agitated and threatening to staff. Placed on 1:1 observation and will continue to monitor. ... 0930 ... Patient continued to be in locked seclusion, yelling, swearing, and threatening staff. Patient then began punching the window repeatedly and became more and more agitated with attempted redirection. Patient was placed in four point restraints and medicated with PRN Ativan and Benadryl. ... 1127... Patient had been in twice as tough restraints. Patient pulled both arms loose and right foot. Patient fell out of bed while left foot remained in restraints. Left foot was immediately released. Pt was lifted from floor by staff and placed back in bed. ... Continued review of MR23 revealed, "... 09/15/19 1649 ... Department of Behavioral Medicine Psychiatric Progress Note ... Patient while in seclusion room, pulled both arm loose and one leg loose and fell out of bed. ... Further review of MR23 revealed, "Consult to Trauma Surgery ... 09/15/19 1257 ... Patient ... was recently discharged from the Trauma Service with left anterior 5-7 rib fractures, T12 compression fracture and left 5th phalanx fracture that had to be placed in 4 point restraints this morning. When Nursing returned, they found the patient with half of body on the floor and their left leg still restrained to the bed. ... ." Review of MR23 revealed, restraint and 1:1 observation checks beginning at 8:45


AM on September 15, 2019, and continuing until 10:45 AM. The patient's behavior was documented as "agitated" consistently while in restraints.

19. Telephone interview with EMP15 on January 23, 2020, at 3:50 PM revealed that the patient was assigned an MHT to do the 1:1 observation and the actual RN overseeing the care of the patient was called away for an admission. EMP20 stated that another RN came to the patient's room and found the patient restrained by the left ankle only. EMP20 was queried why the MHT didn't notify the RN of the patient's behavior and stated that the MHT was not actually paying attention to the patient. EMP20 also stated that this same MHT applied the restraints incorrectly on the patient, that they are color coded and it was noted that they were on the wrong extremities.


20. Telephone interview with EMP17 on January 24, 2020, revealed, "The MHT was outside of the patient's room due to the patient's aggression. Anytime patients are restrained, they are on a 1:1 automatically and staff are to be within arms length of the patient. The MHT had their eyes off of the patient for a few minutes when the other RN saw the patient was off of the bed. ... ."


21. Telephone interview with EMP18 on January 27, 2020, at approximatley 1:45 PM revealed, "... I sat in front of the door with my computer. I took my eyes off of the patient for a couple of seconds to document. ... I had noticed that the ankle restraints were on the patient's wrists and the wrist restraints were on their ankles. I told the Nurse and Security, they said it should be fine. The patient had only one leg restraint on when I turned around."



Cross Reference:

482.13(c)(2) Patient has the right to receive care in a safe setting
482.13(e)(16)(iv) Restraint or Seclusion
482.13(f) Restraint or Seclusion

Based on a review of facility documents, medical records (MR) and staff interviews (EMP) it was determined that Conemaugh Memorial Medical Center failed to provide care in a safe setting by failing to provide 1:1 monitoring for patients identified at high risk for suicide as per doctor order, failed to follow their adopted policy on monitoring patients at risk for suicide, failed to minimize the risk for self-harm by permitting patients identified as high risk for suicide to remain in a public waiting area where staff could not immediately intervene if necessary in seven of 20 medical records (MR29, MR30, MR37, MR38, MR39, MR40 and MR52)

Findings:

1. MR29 was reviewed and revealed the patient presented to Conemaugh Memorial ED for suicidal ideation, assessed for high suicide risk, and was ordered 1:1 observation on January 3, 2020. MR29 failed to reveal any documented evidence that 1:1 observation for this patient occurred.

2. MR30 was reviewed and revealed the patient presented to Conemaugh Memorial ED for mood swings, suicidal ideation and cutting left arm on January 3, 2020, at 9:48 PM. The patient was assessed as a high suicide risk. The patient was triaged and then returned to the public Waiting Room at this time. The patient was placed in an ED cubicle on January 4, 2020 at 1:45 AM. The patient was placed on 15-minute checks at 1:30 AM and continued 15-minute checks until January 4, 2020, at 2:45 AM. At 2:45 AM the patient was ordered 1:1 observation. The patient remained in 1:1 observation until 5:30 AM. At 5:30 AM on January 4, 2020, the patient was on 15-minute checks until 6:15 AM. From 6:15 AM until 8:00AM on January 4, 2020, there is no documented evidence in MR30 of any behavioral checks. At 8:00 AM on January 4, 2020, the patient was placed in 1:1 observation and remained in 1:1 observation with appropriate documentation of behavioral checks until discharge from the Emergency Department at 2:09 PM on January 4, 2020. MR30 failed to reveal documented evidence of a follow-up/re-assessment after 12 hours.

3. MR37 was reviewed and revealed the patient presented to Conemaugh Memorial ED for depression and suicidal ideation on January 6, 2020, at 6:59 PM. The patient was assessed as a high risk for suicide at 6:59 PM and was ordered and placed on 1:1 observation at 7:00 PM. Initial documentation of 1:1 observation was authenticated at 7:30 EMP1 every 15 minutes, consistently until 10:00 PM. The patient was then admitted to a medical inpatient unit.

4. MR38 was reviewed and revealed the patient presented to Conemaugh Memorial ED for superficial cuts to left arm and active suicidal thoughts on January 6, 2020, at 10:08 PM. The patient was assessed as a high risk for suicidal thoughts at 10:10 PM and was ordered and placed on 1:1 observation at 10:30 PM. Initial documentation of 1:1 observation was authenticated at 10:30 PM by EMP12 every 15 minutes, consistently until 11:15 PM, then documentation of 1:1 observation was authenticated at 10:30 PM by EMP1 every 15 minutes, consistently until 1:45 AM on January 7, 2020. 1:1 observation was continued until 7:00 AM, discontinued at 7:29 AM and the patient was then monitored every 15 minutes until discharged via EMS at 8:55 AM.

5. MR39 was reviewed and revealed the patient presented to Conemaugh Memorial ED for suicidal ideations and cuts to wrists with thumb tack on January 6, 2020, at 2:31 PM. The patient was assessed as a moderate suicide risk at 2:19 PM and at a low suicide risk at 2:46 PM. There was no physician order to initiate any behavioral checks, however, documented evidence revealed 1:1 observation began at 8:30 PM on January 6, 2020, as authenticated by EMP1 every 15 minutes, consistently until 1:45 AM January 7, 2020. 1:1 observation documentation continued until 6:45 AM and then the patient was monitored every 15 minutes until discharged via EMS at 9:02 AM. MR39 failed to reveal documented evidence of a follow-up/re-assessment after 12 hours.

6. Further review of MR37 and MR39 revealed documented evidence that EMP1 was monitoring a 1:1 (MR37) while simultaneously monitoring another patient as a 1:1 (MR39) during the hours of 8:30 PM until 10:00 PM.
Further review of MR38 and MR39 revealed documented evidence that EMP1 was monitoring a 1:1 (MR38) while simultaneously monitoring another patient as a 1:1 (MR39) during the hours of 10:30 PM until 1:45 AM.

7. MR40 was reviewed and revealed the patient was seen for suicidal ideation on August 25, 2019, at 3:29 PM. The patient was assessed as a "Level of Risk: 1:1 Continuous Observation" at 3:28 PM and was ordered 1:1 observation on August 25, 2019, at 4:51 PM. Initial documentation of 1:1 observation began at 4:22 PM through 1:00 AM on August 26, 2019. MR40 revealed documented evidence beginning 1:00 AM that the 1:1 was no longer available, patient was in sight of the Nursing Station, curtain was open and 15 minutes checks would be performed until 6:45 PM when the patient was transferred to a tertiary facility. MR40 revealed documented evidence of a follow-up/re-assessment at 11:40 PM, at 5:58 AM on August 26, 2019, at 8:03 AM, and at 12:45 PM.

8. Interview with EMP5 on January 10, 2020, at approximately 11:30 AM and January 24, 2020, at 12:53 PM confirmed the above findings.


9. Review of MR52 revealed, "Clinical Note ... 09/14/19 ... 0910 ... Patient became verbally abusive to other patients and staff, yelling 'shut up you ...' repeatedly. Attempted to redirect patient and patient hit writer and then began kicking at another staff member. Called Security and placed patient in locked seclusion. Patient remains agitated and threatening to staff. Placed on 1:1 observation and will continue to monitor. ... 0930 ... Patient continued to be in locked seclusion, yelling, swearing, and threatening staff. Patient then began punching the window repeatedly and became more and more agitated with attempted redirection. Patient was placed in four point restraints and medicated with PRN Ativan and Benadryl. ... 1127... Patient had been in twice as tough restraints. Patient pulled both arms loose and right foot. Patient fell out of bed while left foot remained in restraints. Left foot was immediately released. Pt was lifted from floor by staff and placed back in bed. ... ."

Continued review of MR52 revealed, "... 09/15/19 1649 ... Department of Behavioral Medicine Psychiatric Progress Note ... Patient while in seclusion room, pulled both arm loose and one leg loose and fell out of bed. ... ."

MR52 revealed "Consult to Trauma Surgery ... 09/15/19 1257 ... Patient ... was recently discharged from the Trauma Service with left anterior 5-7 rib fractures, T12 compression fracture and left 5th phalanx fracture that had to be placed in 4 point restraints this morning. When nursing returned, they found the patient with half of their body on the floor and left leg still restrained to the bed. ... ."

MR52 revealed restraint and 1:1 observation checks beginning at 8:45 AM on September 15, 2019, and continuing until 10:45 AM. The patient's behavior was documented as "agitated" consistently while in restraints. Documentation then revealed that the patient was off the Unit from 11:00 AM until 12:15 PM with documentation of 1:1 observation checks restarted at 12:30 PM.

10. Telephone interview with EMP20 on January 23, 2020, at 3:50 PM revealed that the patient was assigned an MHT to do the 1:1 observation and the actual RN overseeing the care of the patient was called away for an admission. EMP20 stated that another RN came to the patient's room and found the patient restrained by the left ankle only. EMP20 was queried why the MHT didn't notify the RN of the patient's behavior and stated that the MHT was not actually paying attention to the patient. EMP20 also stated that this same MHT applied the restraints incorrectly on the patient, that they are color coded and were on the wrong extremities.

11. Telephone interview with EMP23 on January 24, 2020, revealed, "The MHT was outside of the patient's room due to their aggression. Anytime patients are restrained, they are on a 1:1 automatically and staff are to be within arms length of the patient. The MHT had their eyes off of the patient for a few minutes when another RN saw the patient was off of the bed. ... ."

12. Telephone interview with EMP24 on January 27, 2020, at approximatley 1:45 PM revealed, "... I got pulled from ... Unit to do the 1:1. I sat in front of the door with my computer. I noticed that the patient had the wrong restraints on. Ankle restraints were on the wrists and the wrists were on the ankles. I told the nurse and Security, they said it should be fine. I took my eyes off of the patient for a couple of seconds to document. ... The patient only had one leg restraint on when I turned around."




Cross Reference:
482.13 Patient Rights

Based on a review of facility documents, medical records (MR) and staff interviews (EMP) it was determined that Conemaugh Memorial Medical Center failed to provide care in a safe setting by failing to follow their adopted policies by failing to ensure that the patient's condition or symptoms warranted the use of restraints in 12 of 12 medical records (MR6, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, and MR18) and by failing to apply the restraints as per the physician order in one of 12 medical records (MR6).


Findings:

1. Review of medical record (MR6) was conducted to ascertain appropriate use of restraints. The physician order was written on April 9, 2019 at 6:32 AM, for "Non-violent or Non-Self Destructive Restraint ... Priority: Routine... Physical Restraint: Mitts - Soft Mitts Left Hand. Restraint reason: To prevent from removing vital equipment or interruption in therapies ... ." During a review of the nursing documentation it was noted that the soft mitts were applied to both the right and left hands.

During an interview with EMP11 on October 22, 2019, at approximately 11:00 AM, it was confirmed that the nursing documentation failed to reveal documented behaviors to warrant restraint use.


2. Review of medical record (MR8) was conducted to ascertain appropriate use of restraints. The physician order was written on April 13, 2019 at 12:06 AM, for "Non-violent or Non-Self Destructive Restraint ... Priority: Routine ... Physical Restraint: Soft Limb Restraints (One limb must be free at all times) : Left Arm. Restraint reason: To prevent from removing vital equipment or interruption in therapies." During a review of the nursing documentation it was noted that the patient's right upper extremity was contracted and the left upper arm was weak. It was also documented that only one restraint was applied to the Left Wrist.

During an interview with EMP11 on October 22, 2019, at approximately 11:00 AM, it was confirmed that the nursing documentation failed to reveal documented behaviors to warrant restraint use.


3. Additional review of medical records (MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17 and MR18) specific to restraint usage in the ICU/CCU was conducted. Each medical record revealed documented evidence that all patients were intubated while in restraints. Each medical record revealed that the majority of time the patients were intubated the "Behavior Events" were documented as pulling at oxygen tubing, pulling at NG/OG tube, pulling off cardiac wires and pulling at breathing tube, with corresponding "Visual Checks" documented as lethargic and subdued. Each medical record also revealed that restraints were continued regardless of the patient's status being documented as lethargic and subdued.


4. Following the review of restraint medical record (MR9) with EMP10 and EMP3 on January 7, 2020, at approximately 11:45 AM, interview with EMP3 revealed, "The only choices that the electronic medical record allows you to pick are 'Alert' and 'Lethargic.'"

Interview with EMP10 revealed, "I doubt very much that you will find any annotated nursing notes related to level of consciousness in any of the records."

Both EMP3 and EMP10 stated that there are several levels of consciousness that could describe a patient, but only two are available in EPIC (the electronic medical record).


5. Review of Critical Care Committee meeting minutes dated June 2019-October 2019, revealed restraint usage between 16%-48% on 6 Rose.

Cross Reference:
482.13 Patient Rights

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 policy to ensure the safe application of restraints and by failing to provide continuous monitoring of a patient in four point restraints, in one of one medical record (MR23).



Findings:

1. Review of MR23 revealed, "Clinical Note ... 09/14/19 ... 0910 ... Patient became verbally abusive to other patients and staff, yelling 'shut up you ...' repeatedly. Attempted to redirect patient and patient hit writer and then began kicking at another staff member. Called Security and placed patient in locked seclusion. Patient remains agitated and threatening to staff. Placed on 1:1 observation and will continue to monitor. ... 0930 ... Patient continued to be in locked seclusion, yelling, swearing, and threatening staff. Patient then began punching the window repeatedly and became more and more agitated with attempted redirection. Patient was placed in four point restraints and medicated with PRN Ativan and Benadryl. ... 1127... Patient had been in twice as tough restraints. Patient pulled both arms loose and right foot. Patient fell out of bed while left foot remained in restraints. Left foot was immediately released. Pt was lifted from floor by staff and placed back in bed. ... Continued review of MR23 revealed, "... 09/15/19 1649 ... Department of Behavioral Medicine Psychiatric Progress Note ... Patient while in seclusion room, pulled both arm loose and one leg loose and fell out of bed. ... Further review of MR23 revealed, "Consult to Trauma Surgery ... 09/15/19 1257 ... Patient ... was recently discharged from the Trauma Service with left anterior 5-7 rib fractures, T12 compression fracture and left 5th phalanx fracture that had to be placed in 4 point restraints this morning. When Nursing returned, they found the patient with half of body on the floor and their left leg still restrained to the bed. ... ." Review of MR23 revealed, restraint and 1:1 observation checks beginning at 8:45 AM on September 15, 2019, and continuing until 10:45 AM. The patient's behavior was documented as "agitated" consistently while in restraints.

2. Telephone interview with EMP15 on January 23, 2020, at 3:50 PM revealed that the patient was assigned an MHT to do the 1:1 observation and the actual RN overseeing the care of the patient was called away for an admission. EMP20 stated that another RN came to the patient's room and found the patient restrained by the left ankle only. EMP20 was queried why the MHT didn't notify the RN of the patient's behavior and stated that the MHT was not actually paying attention to the patient. EMP20 also stated that this same MHT applied the restraints incorrectly on the patient, that they are color coded and it was noted that they were on the wrong extremities.


3. Telephone interview with EMP17 on January 24, 2020, revealed, "The MHT was outside of the patient's room due to the patient's aggression. Anytime patients are restrained, they are on a 1:1 automatically and staff are to be within arms length of the patient. The MHT had their eyes off of the patient for a few minutes when the other RN saw the patient was off of the bed. ... ."


4. Telephone interview with EMP18 on January 27, 2020, at approximatley 1:45 PM revealed, "... I sat in front of the door with my computer. I took my eyes off of the patient for a couple of seconds to document. ... I had noticed that the ankle restraints were on the patient's wrists and the wrist restraints were on their ankles. I told the Nurse and Security, they said it should be fine. The patient had only one leg restraint on when I turned around."

Cross Reference:
482.13 Patient Rights

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 follow their adopted Performance Excellence Plan by failing to identify, track, and analyze events, implement preventative actions and report these findings to the Board of Trustees by way of the Performance Excellence Committee (PEC) in nine of nine medical records (MR20, MR21, MR41, MR29, MR30, MR37, MR38, MR39 and MR40).



Findings:

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 in collaboration with the Medical Staff and senior management. Leadership, inclusive of Medical Staff Leadership, 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 of members of the Board of Trustees, Medical Staff Leadership, GME Resident delegates, Administration, and Community Representatives. PEC shall serve as the Board's working committee on all matters pertaining to performance excellence. It will be the vehicle to enhance trust and communication among the Board, corporate officer team, Medical Staff, Allied Health Staff and employees on quality-related matters by providing a candid and confidential forum for discussion. 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; Appointment, reappointment, and privileges to medical staff members, officers and departmental chairpersons; Appointment, reappointment, and privileges as applicable to Allied Health Professionals; Accreditation, licensure and related regulatory survey findings; Patient Safety and Clinical Quality Performance Excellence Program Plan ... Patient Safety/Risk Management; Safety and Emergency Preparedness ... ."

Conemaugh Memorial Medical Center ... PolicyStat ID: 6119805 ... Policy Area: Organizational-Clinical ... 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 personal values and belief systems and strive to protect each patient's dignity. ... Requirements: CHS assures patient rights are supported by the following: 1. An admission policy that ensures that patients are admitted and treated without regard to age, AIDS or HIV status, ancestry, color, disability, education, gender identity, income, language, marital status, national origin, race religious creed, sex, sexual orientation, union membership, or who will pay your bill. ... 4. A policy to render care and treatment appropriate to the patient's condition. The appropriateness of treatment plans, including withholding measures believed necessary to preserve life depends on the medical evaluation of the responsible physician who takes into account the patient's particular situation as well as the assessments of other staff and the desires of the patient or whoever may speak for him. 5. A policy that patients are transferred when the hospital is unable to meet the patient's requests or needs for treatment or services. ... 7. Addressing the psychosocial needs of the patient which are identified during the hospital stay and initiating appropriate referrals as necessary. ... 9. Recognition of the patient's right to formulate an advance directive and to appoint a surrogate to make health care decisions. ... 11. Providing a mechanism for receiving and responding to patient's and family's complaints or grievances concerning the quality of care. This procedure is addressed in the Patient/Customer Complaint / Grievance Policy. 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. ... "

Review of attachment to Patient Rights policy revealed, "A Statement of the Patient's Rights 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. 2. You have the right to receive care no matter what your age, AIDS or HIV status, ancestry, color, disability, education, gender identity, income, language, marital status, national origin, race religious creed, sex, sexual orientation, union membership, or who will pay your bill. ... 9. You have the right to high quality care and professional standards that are always kept and reviewed. 10. You have the right to be fully informed, in a language you can understand, of your health status, including your current medical condition. ... 15. You have the right to be free from any form of restraints (both physical/drug) that is not medically necessary. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid personal discomfort. ... 23. You have the right to request a discharge plan. Upon discharge, you will be given information for your follow-up health care. 24. You have the right to present your advance directive (living will or durable power of attorney for health care). This will be used in case you are unable to make decisions about your care. You may change or withdraw your advance directive by telling your doctor or nurse. 25. You have the right to voice questions, concerns, or comments to your health care provider, to the Patient Representative at the hospital or you may contact the Pennsylvania Department of Health, Acute and Ambulatory Care Services ... 27. The patient's next of kin, guardian, or other appropriate person may carry out these rights if the patient is unable to do so. ... 32. You have the right to access protective and advocacy services. ... ."


Review of Board of Trustee Bylaws of Conemaugh Memorial Medical Center, dated August 2019 revealed "... 'Board of Trustees' or 'Board' means the local governing body appointed by the Corporation exercising those prerogatives and authorities herein and subject to the limitations delineated herein ... Article I ... 1.1 Purpose ... 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 to sick, injured, or disabled persons ... Provide appropriate facilities and services to best serve the needs of patients ... 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 personnel ... 3.11 Responsibilities ... The responsibilities and obligations of the Board shall include: 3.11 (a) Assuming responsibility for Medical Staff oversight and quality care evaluation as described in Section 7.2 and 8.1 if these bylaws ... 3.11 (d) Establishing, maintaining and supporting, through the CEO and 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, compliance with applicable law (Medicare regulations and other applicable regulations) and development, review and revision of policies and procedures ... 3.11 (q) Conducting an annual evaluation of its own activities and performance; 3.11 (r) Conducting an annual evaluation of the CEO; and communicating same to the appropriate officer of the Corporation. 3.11 (s) Establishing mechanisms to assure that all patients with the same health care problem are receiving the same level of care in the Hospital; 3.11 (t) Designating particular individuals or departments responsible for evaluating and monitoring quality of care in particular patient services, and fostering communication between such individuals or departments through establishing timeframes for discussion of these issues ... 3.11 (y) Assuming responsibility for the effective operation of the grievance process, which process the Board hereby delegates to the Patient Relations Department to be handled in accordance with Board approved policies, which policies shall include, at minimum, a requirement that quarterly summaries/reports be submitted to the Board through the Performance Excellence Committee (committee of the Board) ... Article V ... 5.4 Performance Excellence Committee. The Performance Excellence Committee shall serve as the Board's working committee on all matters pertaining to quality, making recommendations to the full Board. The members of the Performance Excellence Committee will be appointed by the Chair of the Board and serve a one year term. Members may succeed themselves. It will be the vehicle to enhance trust and communication among the Board, corporate office team and Medical Staff on quality-related matters by providing a candid and confidential forum for discussion. The committee's responsibilities include reviewing and making recommendations on the following: corporate commitment to quality (advocate and champions); objective measure to gauge the quality of care and services being provided such that all patients with the same health problems are receiving the same level of care; risk management; quality management programs; appointment; reappointment and privileges of Medical Staff members, officers and departmental chairs; accreditation, licensure and related regulatory survey findings; quality-related policies; Quality Assurance and Utilization's Management Plans; education programs on quality; continuing education for Board; and the Medical Center's education programs ... At least semi-annually, the committee shall meet with the Chief of the Medical Staff to discuss matters including, but not limited to, the scope and complexity of hospital services offered, specific patient populations served by the hospital, and any issues of patient safety and quality of care ... Article VI ... 6.2 ... The Board of Trustees shall provided to Corporation an annual evaluation of the CEO's performance ... 6.3 ... The authority and duties of the CEO shall include responsibility for the following: 6.3 (a) Carrying out all policies as established by Corporation; 6.3 (b) Establishing, reviewing, and where appropriate, adjusting charges within the framework of policies established by Corporation ... 6.3 (m) Being responsible for assuring that the Hospital is in conformity with the requirements of planning, regulatory and inspecting agencies; reviewing, advising and acting promptly upon the reports of such agencies ... Article VIII ... 8.1. Board responsibility for the Quality of Professional Services. After considering the recommendations of the Medical Staff and the other health care professionals providing patient care services, the Board shall implement specific review and evaluation activities to assess, preserve and improve the overall quality and efficiency of patient care in the Hospital. The Board, through the CEO, shall provide whatever administrative assistance is reasonable necessary to support and facilitate activities contributing to continuous quality assessment and improvement ... ."



Review of the facility's policy entitled Event/Incident Reports, reviewed August 2018, revealed, "... It is the policy of Conemaugh Health System that all events/incidents be reported promptly. Prompt reporting of events/incidents is necessary to protect patients, visitors, employees and students against hazards as well as to provide a complete and accurate record of the event/incident. Requirements An event/incident is defined as A. Any disruption of routine such as: ... 2. Procedure errors including medication and or treatment errors, reporting errors and identification errors. ... B. Any condition which may cause a safety or health impairment including: 1. An unsafe mechanical or physical condition. 2. An unsafe practice. C. Any unusual breakdown in normal pattern of business; any occurrence not consistent with routine care of a patient, the routine service of a department, or the routine operation of the facility. ... The Event/Incident Report is a factual account of the details of an event and provides a method for discovery and a means for an investigation of causes. The specific purposes are: 1. To improve patient care by assuring that appropriate and immediate intervention is done on the patient's behalf and that there is a subsequent prevention of recurrence. 2. To provide a data base to evaluate and develop adequate standards of care. ... Procedure for SEM Event/Incident Reports Patients and Visitors: Statement of Purpose: This procedure is to be followed for completing the Patient Event/Incident Report form. Requirements ... 8. When notified of an event/incident in his/her area, management is responsible for immediately taking action to mitigate harm to involves parties, for performing and documenting follow-ups, and for taking appropriate action to prevent a recurrence ... 10. Role definition in SRM will be granted by the Risk Management Department according to the following guidelines ... Complete the event report on line promptly once an event is discovered. Manager: Complete initial investigation of event report, completing the first level follow-up of event including the assignment of severity as soon as possible after receiving email notification. Risk Management: Review events as email notification arrives. Assigns follow-ups as needed ... Department Leader (Director/Manager) ... Responsible for logging into SRM daily and checking for any events that have occurred in department since the last time they reviewed their event queue. When an event is reported, department director/managers are notified via e-mail to log into SRM and view the details. Responsible for completing or assigning follow-up investigations within the designated time frame and for running reports. Responsible for implementing interventions to prevent recurrence as appropriate ... Investigator ... Responsible for completing follow-up investigations on events as assigned and for documenting findings in the SRM system database ... ."


Review of Discharge Planning and Referrals of Patients to Post Discharge Providers, Policy Stat ID 7284750, last reviewed December 2019, revealed, "... Purpose: ... The discharge planning process and the discharge plan must be consistent with: the patient's goals for care and his or her treatment preferences, ensure an effective transition of the patient from the hospital to post-discharge care, and reduce factors leading to preventable hospital readmissions."


Review of Discharges from the Department of Emergency Medicine and Patient Referrals, Policy Stat ID 5970583, last reviewed February 2019, revealed, "All patients to be discharged should have appropriate treatment and follow-up care plans discussed with them prior to discharge. ... ."


Review of the policy entitled Patient Observation 1:1, dated January 2019, 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 ... 1:1 staff member's first initial and full last name will be documented on the Unit's assignment sheet along with their shift time frame, assigned lunch break, and spectra-link number ... 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. Within 5 feet of the patient at all times while observing patients who are on moderate suicide risk precautions, and those patients being observed for exhibiting harmful/risky behavior. 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 ... 1:1 observation is required for patients who are in violent & destructive behavioral restraints ... ."




1. Review of MR20, MR21 and MR41 revealed that all three patients presented to the Emergency Department via EMS for treatment and were discharged prior to ensuring a safe discharge plan and mode of transportation that was communicated to other significant persons involved in the patient's aftercare. Two of these patients were residents of care homes (MR20 and MR21).

Interview with EMP6 on Janaury 17, 2020, at 10:51 AM confirmed that an SRM/Event report was not completed on either of the above events (MR20 and MR21).

EMP6 was queried on January 24, 2020, to confirm if any discussion of Complaint/Grievances (MR20 and MR21) was documented in Patient/Safety Committee, Performance Excellence Committee (PEC), or Board of Trustees Committee meeting minutes. EMP6 confirmed on January 24, 2020, at 12:06 PM, "Not specifically-our quarterly report outs on complaints and grievances (at PE Steering and PEC are numeric only) ... ."

2. The above grievances (MR20 and MR21) were reviewed in the presence of the Survey Team, EMP21 and EMP6 on January 10, 2020 at approximately 2:45 PM. EMP21 stated that EMP21 was not aware of the happenings that occurred or that grievances were received for MR20 or MR21.



3. Review of MR29, MR30, MR37, MR38, MR39 and MR40 revealed that all Emergency Department patients were not provided 1:1 observation as indicated in the facility's adopted policy.


Interview with EMP5 on January 10, 2020, at approximately 11:30 AM and January 24, 2020, at 12:53 PM confirmed the above findings.


4. Review of Performance Excellence Steering Committee (PESC) meeting minutes dated February 13, 2019, April 10, 2019, May 8, 2019, June 12, 2019, and August 14, 2019, was completed. The minutes reflected activities/discussion/review including, but not limited to, stroke dashboard, service line reports, mortality reports, restraints, clinical dashboard review, falls and injury dashboard, clinical excellence reports, serious event and root cause analysis review. The minutes failed to reveal documented evidence specific to the details of each complaint/grievance, only dashboard numeric values were reported. There is no documentation that the facility has tracked, or analyzed these events and/or implemented preventative actions.




6. Review of Performance Excellence Committee (PEC) meeting minutes dated February 20, 2019, March 20, 2019, May 15, 2019, June 19, 2019, and July 17, 2019, and October 16, 2019, was completed. The minutes reflected activity review/discussion, including, but not limited to restraint usage, dashboard review, patient relations grievance reports, patient safety reports, medical staff reports, review of PE Steering minutes, serious event tracking, environmental and safety dashboard, infection rates, hand hygiene monitors, and various service line reports, regulatory reports, falls, and medical staff reports. The minutes failed to reveal documented evidence specific to the details of each complaint/grievance, only dashboard numeric values were reported. There is no documentation that the facility has tracked, or analyzed these events and/or implemented preventative actions.





7. More specifically, "Performance Excellence Committee of the Conemaugh Memorial Medical Center Board of Directors" meeting minutes dated June 19, 2019, revealed that second quarterly report 2019, revealed 357 patients were assisted by the Patient Relations Department. Complaints/grievances regarding staff attitude and care continue to be the top of the list for complaints. Care issues were broken down and the top three complaints were Treatment Plan, Communication and Skill Competency. Treatment Plan break down revealed the ED to have the highest number of complaints in the category. Staff Attitude-top four issues were the Lack of Attentiveness, Lack of Personalized Care, Rudeness and Unprofessional Behavior. The minutes failed to reveal documented evidence specific to the details of each complaint/grievance, only dashboard numeric values were reported. There is no documentation that the facility has tracked, or analyzed these events and/or implemented preventative actions.





8. More specifically, "Performance Excellence Committee of the Conemaugh Memorial Medical Center Board of Directors" meeting minutes dated October 16, 2019, revealed the third quarterly report 2019, with 85 issues handled by Patient Relations in Q3-181 Complaints and Grievances were handled by the Patient Relations Department in the 3Q. 103 In-Patient concerns were handled on site therefore avoiding them turning in to grievances. 101 calls were fielded for assistance. Care issues, staff attitude ... mostly physican issues compared to nursing and ancillary staff. Staff Attitude. Review of the Complaints & Grievances for July - September 2019 revealed Physician & RN issues totaled 84; Staff Attitude and behavioral issues totaled 58, these two issues were the highest number of patient concerns. In addition there were 187 other patient concerns which include but was not limited to: dietary, service, lost property, discharge issues, billing and lab issues. The minutes failed to reveal documented evidence specific to the details of each complaint/grievance, only dashboard numeric values were reported.

Based on review of facility documents, medical records (MR) and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow adopted policies by failing to ensure that unfavorable conditions were investigated, analyzed and/or implemented corrective action, and reported to the Board for six of eight medical records (MR20, MR21, MR26, MR27, MR28 and MR29) and by failing to follow adopted staffing matrix to ensure the appropriate number of Registered Nurses based on patient census were assigned to critical care patients in nine of 22 shifts.



Findings Include:

Review of the facility's policy entitled "Event/Incident Reports" reviewed August 2018, revealed, "... It is the policy of Conemaugh Health System that all events/incidents be reported promptly. Prompt reporting of events/incidents is necessary to protect patients, visitors, employees and students against hazards as well as to provide a complete and accurate record of the event/incident. Requirements: An event/incident is defined as: A. Any disruption of routine such as: ... 2. Procedure errors including medication and or treatment errors, reporting errors and identification errors. ... B. Any condition which may cause a safety or health impairment including: 1. An unsafe mechanical or physical condition. 2. An unsafe practice. C. Any unusual breakdown in normal pattern of business; any occurrence not consistent with routine care of a patient, the routine service of a department, or the routine operation of the facility. ... The Event/Incident Report is a factual account of the details of an event and provides a method for discovery and a means for an investigation of causes. The specific purposes are: 1. To improve patient care by assuring that appropriate and immediate intervention is done on the patient's behalf and that there is a subsequent prevention of recurrence. 2. To provide a data base to evaluate and develop adequate standards of care. ... Procedure for SEM Event/Incident Reports: Patients and Visitors: Statement of Purpose: This procedure is to be followed for completing the Patient Event/Incident Report form. Requirements ... 8. When notified of an event/incident in his/her area, management is responsible for immediately taking action to mitigate harm to involves parties, for performing and documenting follow-ups, and for taking appropriate action to prevent a recurrence ... 10. Role definition in SRM will be granted by the Risk Management Department according to the following guidelines ... Complete the event report on line promptly once an event is discovered. Manager: Complete initial investigation of event report, completing the first level follow-up of event including the assignment of severity as soon as possible after receiving email notification. Risk Management: Review events as email notification arrives. Assigns follow-ups as needed ... Department Leader (Director/Manager) ... Responsible for logging into SRM daily and checking for any events that have occurred in department since the last time they reviewed their event queue. When an event is reported, department director/managers are notified via e-mail to log into SRM and view the details. Responsible for completing or assigning follow-up investigations within the designated time frame and for running reports. Responsible for implementing interventions to prevent recurrence as appropriate ... Investigator ... Responsible for completing follow-up investigations on events as assigned and for documenting findings in the SRM system database ... ."




Conemaugh Memorial Medical Center Policy Stat ID: 5765751 ... Last Reviewed: Janaury 2019 ... Patient Safety and Clinical Quality Performance Excellence Program Plan, revealed, "... Introduction/Preface Memorial Medical Center's Board of Trustees is committed to making communities healthier. To make this a reality, we need to effectively communicate our mission, vision, our commitment to Performance Excellence, and our strategic planning priorities to all stakeholders. Our Performance Excellence activities will encompass our pillars of excellence including Quality and Service Growth, Excellence in Operations, High Performing Talent in order to achieve our vision. ... Strategic Plan Deployment/Journey of excellence and Planning Process Memorial Medical Center's strategic planning and deployment focuses on specific challenges derived from an assessment of our organization's strengths, weaknesses, opportunities and threats (SWOT) and an environmental scan. In order to maintain organizational focus on our deployment of our strategic plan, monthly operating reviews are held in which the DLP Quality Scorecard is overviewed. Bi-annual reports are given regarding progress on Quality, Patient Safety and Patient Experience to the Quality Oversight Committee at Duke LifePoint. In addition, MMC's dashboards are used as a systematic evaluation of our organizational performance. Our strategic plan deployment permeates through our organization as depicted in the following schematic. ... A. Board of Trustees The Board is responsible to set the direction for performance excellence in collaboration with the Medical Staff and senior management. ... C. 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 ... PEC shall serve as the Board's working committee on all matters pertaining to performance excellence ... Measurement of both process and outcome for high volume, high risk, high cost, and/or problem prone processes or populations is required. Data collected is then trended, analyzed and prioritized. Department managers report the results of their performance excellence activity to their senior leader and these unit specific results are discussed at staff meetings and displayed on unit Quality Boards. Based on the magnitude of the issue, it may be resolved at the departmental level and/or channeled to PEC. Team leaders from these areas discuss Define, Analyze, Measure, Improve, and Control phases of their Lean departmental/organizational projects at the Council for PE for transformation, innovation, and integration and for continued cycles of learning purposes ... O. Knowledge Management. Data is systematically collected in order to design new processes, assess dimensions of performance relevant to processes, outcomes, and functions, determine level of stability of important processes, identify possible opportunities for Excellence, and determine if excellence efforts have resulted in desired changes. The detail and frequency of data collected will be determined based on the impact of the process or activity being measured. ... U. Failure Mode and Effects Analysis. FMEA is applied, when necessary, to any high-risk patient care processes. An interdisciplinary team performs a rigorous analysis of the process, identifying potential failure modes and mechanisms to prevent those failures. The process improvement recommendations of the FMEA are reported to the PE Steering up to PEC ... Performance Excellence Process ... Performance Excellence Teams (PET) have been selected by each operating unit, and are inclusive of all levels of staff within those operating units. Operating Units may be service lines, departments, divisions, administrative units, or simply functionally related services ... Each operating unit is responsible to review relevant input to determine opportunities for Excellence ... The Compliance Hot Line and SRM near miss/incident reporting are additional vehicles that can be used to vet an issue or concern in person or anonymously. Identified issues are referred by the PE Steering Committee to the appropriate person or team for evaluation and action. Referrals are also tracked to and form PE Steering to Medical Staff PE/Peer review/to Nursing Peer Review/to CME Steering. ... ."


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. During the Strategic Planning Process, the Organizational Plan for providing patient care will be reviewed and revised as necessary. Changes in patient care needs or findings from Performance Excellence activities, Risk Management, Patient Safety, Infection Control, Lean Six Sigma projects and other internal assessments may also trigger a review and revision. 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. G. Information from performance excellence activities. 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. ... Vision and Values In collaboration with the community, Memorial Medical Center will provide patient-focused care through: ... E. Provision of services for access, admission, testing, treatment and discharge that are appropriate to the scope and level required by the patients to be served. 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. Definition of patient care, patient services, and patient support service Patient services at Memorial Medical Center occur through an organized and systematic process designed to ensure the delivery of safe, effective, timely, evidence-based, relationship-based care and treatment. Provision of patient care services and the delivery of patient care requires specialized knowledge, judgement, and skill derived from the principles of biological, physical, behavioral, psychosocial, and medical sciences. As such, patient services will be planned, coordinated, provided, delegated and supervised by professional helath 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. Patient Care Areas Inpatient Care Units: Ashman 6 Critical Care ... Rose 6 Critical Care ... DEM Department of Emergency Medicine & Ultra Track ... 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. Each patient care service area collaborates with the Medical Staff to provide effective patient care. The Medical Staff is responsible for the medical plan of care and has the responsibility to assess and improve patient care. The Medical Staff's role in the process of policy development and excellence is pivotal within the organization. Individuals with clinical privileges provide medical services in accordance with the Bylaws, Rules and Regulations of the Medical Staff. ... 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. Patient Care/Organizational Performance Excellence All departments will be responsible for following the hospital's plan for Performance Excellence including planned performance assessment and improvement activities, initiating activities designed to follow-up on unusual occurrences or specific concerns/issues. ... ."



Review of Departmental Plan for Provision of Care-Critical Care Units Policy, Policy Stat ID 6321056, last reviewed June 2019, revealed, "... Objectives To meet patient needs by: Promoting multi-disciplinary collaboration and teamwork to provide the right care at the right time to achieve realistic patient outcome and patient safety. Studying/monitoring care processes continuously, changing them as needed to enhance patient outcome and safety. ... Scope: Twenty-five critical care beds are located on A6/R6 of the Ashman/Rose Pavilion. Ashman 6 is a 14 bed Medical-Surgical Critical Care Unit. 6 Rose is a 11 bed Medical-Surgical Critical Care Unit. These units are designed and staffed to provide optimum facilities, equipment, and medications to care for seriously and critically ill patients by physicians, specially trained nurses, respiratory therapists, and support staff 24 hours per day, 7 days a week. ... Nursing: Nurses who have special training in critical care nursing will staff these critical care units. This training includes EKG interpretation, resuscitative procedures, cardiopulmonary monitoring, neurological monitoring, and use of vasoactive medications. The nurse managers or charge nurses makes nursing care assignments. Assignments are based upon the matching of nurse skill to patient needs including technology required to care for the patient. Staffing is adjusted according to patient acuity and needs. ... Critical Care Assignments: Patients who may require 1 RN to 1 Nurse assignment include: Open Heart surgery patients until stabilized, Licox monitoring, CRRT, Continuous EEG monitoring with pentobarb infusion, Highly unstable trauma admits, Hemodynamic or neurologic instability, Pronation therapy-manual or mechanical, Unstable IABP, Impella Therapy, Patients going on for organ recovery-if unstable, Those ordered by physician due to hemodynamic instability requiring constant care, Patients requiring desensitization therapy, Post Alteplase patients (stroke), Post Endovascular procedure. 2 RNs to 1 Patient assignments may include: ECMO with multiple vaso pressors, CRRT. Patients who cannot be part of a 3 patient assignment: Patients admitted to the Trauma Service, Post op Open heart surgery patients ... B. Capacity Management 1. Preemptive conversations will occur between the critical care charge nurse, the Director of Nursing /AD and the Department of Emergency Medicine (DEM) supervisor as the critical care beds reach nearly full to full capacity in the intensive care units. ... ."


Review of Nurse Staffing Plan Policy, Policy Stat ID 5624867, last reviewed November 2018 revealed "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. Staffing Plan Addresses the Following: Staffing grids are designed for each individual Nursing Unit. Each department and the Staffing Office/AD have the current staffing grids ... 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 Conemaugh Memorial Medical Center ... PolicyStat ID: 2454532 ... Last Revised: July 2016 ... Criteria for 1:1 Patient Management in Critical Care Management in Critical Care policy and procedure. "Overview Purpose: It is recognized that there is a certain patient population requiring advanced critical care intervention and monitoring. These highly acute patients require a patient to registered nurse ratio of one to one (1:1). Staffing is to be adjusted to assure that the patient is cared for to this standard of care. Expected outcomes: A 1:1 registered nurse to patient ratio is to be maintained for the duration of the time that is necessary. Contraindications: This is not to be confused nor is it interchangeable with the procedure for 1:1 observations of a patient that may have behavioral or safety indications for the observation status. Refer 1:1 Observation for Destructive Behavior policy. Points of Emphasis: Specific competencies are to be maintained by registered nurses assigned to care for 1:1 patients in the critical care units. Criteria for 1:1 Patient Management in Critical Care Below are common reasons for 1:1 patient management in Critical Care units. This list is not all inclusive. 1:1 monitoring can be ordered by the physician as needed. There also may be instances where the registered nurse to patient ratio required is 2:1 or greater. These cases are determined on an individual basis. Rational for higher acuity is to be documented by the Critical Care Charge Nurse on the Critical Care Charge Nurse Worksheet and communicated to the managers. Cardiothoracic surgery ... Continuous Renal Replacement Therapy (CRRT) ... Trauma/Surgical Patients ... Medical Patients ... hemodynamic management and/or neuro instability. Ordered by physician. ... Continuous EEG Monitoring with Burst ... Lic Catheter Brain Oxygenation Monitoring ... Impella ... Rotoprone ... ."

Review of "Conemaugh Health System Job Description-(Executive Director of Cardiovascular Service Line)" dated June 2019, revealed, "... Supervises: ... Nurse Manager: 7 Rose, 7 Ashman, 6 Rose, 6 Ashman ... Job Summary: In collaboration with the Cardiac Service Line Physician Medical Director, the Cardiac Executive Director is responsible for management, development, financial control, measurement, and implementation of program initiatives for the Cardiac Service Line for CHS. ... This role requires skills in project management, and analysis. ... Specific areas of accountability include: ... Critical Care, and Inpatient Cardiac Units. Expected to work collaboratively with all Health System entities in the development of a system-wide Cardiac Service Line approach. ... Recommends a sufficient number of qualified and competent persons to provide care/services; Determines the qualifications and competence of department/service staff who provide patient care services and who are not licensed independent practitioners; Continuously assesses and improves the performance of care and services provided; Maintains quality control programs, as appropriate; ... Understands, communicates and supports the organizations compensation philosophy, policies, plans and programs. Supervisory Responsibilities ... ."




Review of "'Appendix B'-Rules and Regulations" dated May 28, 2019, revealed, "... Article IX-Hospital Committees ... 9.1 Critical Care Committee 1. Membership a. Surgical Critical Care Director, Medical Critical Care Director, Emergency Medicine Chair, Director of Coronary Care Unit, Director of GME, Director of Trauma Program, Director of Hospitalist Program, Nurse Managers, Neurosurgeon (ad hoc), Member from Division of Anesthesiology (ad hoc), PharmD providing coverage for ICU, Director Respiratory Therapy and selected residents. b. Chair of this committee alternates between Director of Surgical Critical Care (1st and 3rd quarters) and Director of Critical Care Unit (2nd and 4th quarters). If these physicians are unavailable to serve as chair, the position will be filled by CMO or VPMA. 2. Duties a. Establishes, implements and reviews on at least an annual basis the policies and procedures relating to the delivery of care to the critically ill with the institution which includes the policies and procedures of the medical and surgical intensive care units, the coronary care unit, the monitored beds and for the delivery of resuscitative care through the medical center. b. Critical Care Units are responsible for a Quality Assurance Program that embraces transition to and from the unit, as well as care in the unit. This information is provided to the Critical Care Committee for their review and suggestions c. Each department/division which has medical staff who admit to the Critical Care Units submits their portion of the quality assurance report, which covers such patients, to the Critical Care Committee for information. d. Critical Care Committee may undertake any review or analysis of the quality of care delivered in the Units or by the CPR team. e. Develops effective policies for controlling the utilization of unit beds. 3. Meetings a. Meets at the call of the Chair, but not less that [sic] quarterly and maintains a record of its proceedings and actions 4. Reports a. Critical Care Committee reports directly to the MEC. ... ."





1. Electronic mail documentation received from EMP16 on January 8, 2020, revealed, "... The SEM system is set up to act like an email If when we reviewed those events determined to be a 'staffing issue' The event report was e mailed to [EMP12], [EMP19], the nurse manager, [EMP13] & me [EMP16]; so in all reality everyone was notified. ... When a manager / director is set up in SEM it is decided what their role will be and what events they have access to; based on their job and departments they are responsible for. ... Anyone who has access to an event has an inbox and can view / manage any event in their inbox ... Anyone can assign a follow-up to themselves or anyone else ... Anyone with access to an event can add a note to the event ... Anyone with access to an event can add an attachment ... ."


2. Following discussion of the Event/Incident reporting policy, interview with EMP13 on January 7, 2020, at approximately 2:20 PM, EMP13 confirmed SRM events are received electronically, reviewed and fully investigated.


3. Review of Event Summary Report dated May 1, 2019, to November 25, 2019, specific to ICU and CCU, revealed a total of 183 events related to deaths in restraints, skin integrity issues, pharmacy medication delays, dietary issues, staffing/tripled assignments and missing patient belongings. Eight concerns were chosen for further detailed review.


Facility documentation related to medical record (MR20) dated October 5, 2019, 7:00 AM revealed an concern related to a delay in patient's CRRT treatment due to the RNs tripled patient assignment. The documentation stated that the patient's CRRT could not be started until the other two patients could be transferred out of CCU because the CRRT required a one to one.

Following review of the staffing schedule/assignment sheet and interview with EMP10 on January 7, 2020, at approximately 12:00 PM, it was confirmed that 7A-7P shift on October 5, 2019, was short one RN as per staffing matrix.

Review of medical record (MR20)-CRRT Event-dated October 5, 2019, revealed, "... Nursing Note 10/05/19 0448 ... Talked to ... about pt receiving Lasix. Stated that pt receiving evening dose and had no response. Pt foley was flushed and pt bladder scanned for 0 ml. Asked if ... wanted another dose of Lasix given considering the pt CR was increasing. Stated to hold current dose and will be discussed in AM. ... 0704 ... Spoke to ... about pt urine output being marginal all night right around 30-35 an hour. Also notified about pt CR of 3.6. Stated that Nephrology was already on consult. ... stated that ... would have the intern talk with nephrology today. Will pass on in report. ... 2350 Filter clogged at this time. Unable to flush pt back, because CRRT machine stated with clots not to flush back. ... notified that blood was not returned so H and H may be low on AM labs. Also notified that Pt will be restarted at this time ... 10/06/19 0044 Pt restarted at this time with no difficulties. Will continue to monitor pt ... ." Continued review of MR20 revealed that the Hemodialysis catheter was placed under ultrasound on October 5, 2019, at 10:00 AM and flowsheet documentation of the CRRT treatment began at 3:30 PM on October 5, 2019.

Telephone interview with EMP9 on November 27, 2019, at approximately 12:00 PM revealed, "... Concerns were reviewed with [EMP13], nothing changed. On October 4th, an open heart patient coded. There was limited staffing. The other patient [MR21]was bleeding, [MR21] was an ... immigrant. ... [MR21] Impella was out, [MR21] was repagination. [MR21] had guards in his room that got help. Throughout the day, things got delayed. A CRRT patient had to wait five hours for their treatment to be started. ... ."



Facility documentation related to medical record (MR21) dated October 5, 2019, 10:30 AM revealed a tripled assignment that posed a safety concern to a staff member. One of the patients (MR21) in the tripled assignment began to bleed heavily from a groin site in which an Impella device was recently removed. The documentation also stated that this patient had several guards, was restrained, and required several staff members to hold down so that care could be provided safely.

Following review of the staffing schedule/assignment sheet and interview with EMP10 on January 7, 2020, at approximately 12:00 PM, it was confirmed that 7A-7P shift on October 5, 2019, was short one RN as per staffing matrix.

Interview with EMP8 on November 25, 2019, at 1:45 PM revealed, "... A few months ago we had several triples and a 1:1. There was a patient coding on daylight. An RN tripled had an inmate who was repagination [MR21]. It took everyone, students, managers, social services to help save both of these lives. I understand that we do not need to staff for the 'what if?' Nurses are putting in SRM regarding safe staffing and the provison of care not being followed. ... ."

Review of medical record (MR21) dated October 5, 2019, revealed, "... Progress Notes ... 10/05/19 1356 ... The reason the patient is critically ill is: agitated violent delirium requiring several peace officers to hold patient down, in the context of recent exsanguinating bleed from past femoral artery Impella site. S/P STEMI and stents to RCA and Left Main. Aspiration pneumonia on Zosyn. On vent. ... Physical Exam: ... Constitutional: Comments: Sedated with propofol, on ventilator shivering, no more bleeding from the fem-stop. ... Musculoskeletal: ... Comments: Left inguinal area clammed [sic] from the fem stop ... Assessment & Plan: ... # Cardiovascular ... # Cardiogenic shock on Impella (removed 10/03/19) ... femstat stays for another 24 hours ... # Hem/Onc Hemorrhagic shock 2/2 blood loss vs Cardiogenic shock pt had acute bleed from left groin site this AM pressure held to groin and femstop placed pt being transfused 6 PRBCs with close monitoring of H&H ... # General ... Family issues: ... imigrant [sic]. No family present, inmate. Looking for translator when patient is extubated to assess understanding of his medication and issues. ... ."



Facility documentation related to medical record (MR24) dated July 16, 2019, 2:30 PM revealed a delay in administration of insulin and obtaining blood sugar levels prior to a patient being transferred out of the Intensive Care Unit to a step down unit.

The concern was investigated on July 17, 2019, as assigned by the nurse manager, but lacked documented evidence of a corrective action plan.

Following review of the staffing schedule/assignment sheet and interview with EMP10 on January 7, 2020, at approximately 12:00 PM, it was confirmed that 7A-7P shift on July 16, 2019, was short one RN as per staffing matrix.


Facility documentation related to medical record (MR25) dated September 8, 2019, at 7:00 PM revealed a concern related to a tripled assignment that posed a safety concern to a staff member. One patient had an open ventricular device (EVD) to continuous drainage that the employee could not monitor closely enough due to caring for two other high acuity patients.

The concern was investigated on September 9, 2019, as assigned by the nurse manager. The investigation summary revealed that there were only three RNs scheduled on 6 Rose (CCU) and seven RNs on 6 Ashman (ICU). There were three patients on 6 Ashman with transfer orders but because the medical floors had staffing issues of their own, they could not take the patients. The investigation summary also revealed that 6 Rose (CCU) is currently down seven full time positions and 6 Ashman is currently down five full time positions and that they are unable to adequately staff an ICU with twenty-five beds. The investigation lacked documented evidence of a corrective action plan.

Following review of the staffing schedule/assignment sheet and interview with EMP10 on January 7, 2020, at approximately 12:00 PM, it was confirmed that 7A-7P and 7P-7A shift on September 8, 2019, was short one RN each shift as per staffing matrix.

Interview with EMP8 on November 25, 2019, at 1:45 PM revealed, "... An EVD (External Ventricular Device) patient used to be a 1:1. Now this patient can be part of a tripled assignment when they were not tripled before. If that patient drained more than 20 cc and I wasn't in there, and something happened, I would have to enter an event. The Charge Nurse, Nurse Manager and AD told us not to enter them. I've been her 10 years and have never seen it this bad. ... ."


Facility documentation related to medical record (MR26) dated September 19, 2019, at 7:00 PM