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Based on review of facility documents, personnel files (PF), and staff interview (EMP), it was determined the facility failed to ensure annual employee evaluations were completed accurately and timely for two of seven personnel files reviewed (PF1 and PF7); and failed to ensure their attendance disciplinary process was followed for one of one personnel files reviewed (PF1).

Findings:

1) Review on September 11, 2023, of the facility policy, "Performance Management," last reviewed May 12, 2021, revealed "...I. Scope This policy applies to all LVHN employees except where superseded by language contained in a collective bargaining agreement. ... II. Policy Lehigh Valley Health Network's (LVHN) mission is to heal, comfort and care for the people of our community by providing advanced and compassionate health care of superior quality and value supported by the education and clinical research. We fulfill this commitment to our community when all employees are at their best. LVHN promotes a culture of diversity, equity and inclusion, and the Performance Management process supports our employees to be their best. It is designed to maximize individual and, by extension, organizational performance. Performance Management includes setting expectations, aligning individual efforts to achieve organizational goals, monitoring employee behavior and results, providing feedback and coaching, and assessing performance each fiscal year. The benefits of a well-implemented Performance Management process include: employees receive regular feedback on their performance; employees receive guidance, support and developmental opportunities in line with their needs; managers evaluate the contributions of team members fairly; and stronger organizational performance and achievement of network goals. III. Definitions ... Performance Plans: Employees are assigned one of two PeopleFluent Performance Plans: Performance Plan - includes employees who are Staff through Manager level. ... Year-End Review - a sub-process of Performance Management whereby the employee and manager individually assess the employee's full fiscal-year performance (job performance, behavioral performance, and performance goal results) and meet to discuss the assessment. The manager assigns a Performance level to the employee. IV. Provision Employee Responsibility It is the responsibility of the employee to be aware of and abide by existing rules and regulations of LVHN and perform his/her duties to the best of his/her ability to the standards as set forth in the job description or as otherwise established by management. Employees are encouraged to take advantage of all learning opportunities available and request additional instruction when needed. LVHN Management Responsibility It is the responsibility of LVHN Management to be aware of and abide by existing rules and regulations of LVHN and perform his/her duties to the best of his/her ability to the standards as set forth in the job description or as otherwise established by their manager. With respect to the Performance Management process, LVHN Management is responsible to ensure all of their direct reports follow and complete the process and adhere to regulatory requirements. V. Procedure The Performance Management process has been outlined in the three (3) Tip Sheets contained in the Attachments section. VI. Attachments ... Year-End Review Tip Sheet - Attachment D ... Year-End Review: Tip Sheet The PeopleFluent Year-End Review workflow involves 6 steps: 1 Self-Review 2 Peer Review 3 Manger Review 4 Review Discussion 5 Colleague Acknowledgement 6 Completed ... Step 3 - Manager Review (June 16 - August 15) ... The manager enters comments regarding their colleagues' performance. The manager checks the Organization & Regulatory compliance box (Yes/No). Yes = Complaint. No = Not compliant. The manager assigns the Performance Category based on the guidelines per the Performance Management policy posted on the Colleague Resource Center (CRC). After the Manager completes all updates and submits the form, the Year-End Review is advanced to Step 4, Review Discussion. Step 4 - review Discussion (June 16 - August 15) The manager and colleague meet to discuss the colleague's performance. ... The manager acknowledges the review took place and submits the form, which advances it to Step 5, Colleague Acknowledgement. Step 5 Colleague Acknowledgment (June 16 - August 15) ... The colleague acknowledges the review took place and submits the form, which advances it to Step 6, Completed. After August 15, any in progress Year-End Review will be pushed forward to Step 6. Step 6 Completed (by August 15) The Year-End Review is completed. No additional action is necessary."

Review on September 11, 2023, of PF1, revealed PF1 was hired on August 22, 2022. There was documentation of PF1's Performance Plan for 2023. There was documentation PF1 met all organization policies, attendance, compliance and regulatory requirements associated with their position in a timely manner. There was documentation PF1 was categorized as a Successful Performer and overall performance was consistent, valued and reflected high quality of work. There was no documentation PF1 had experienced time and attendance issues throughout the last year. There was documentation the annual Performance Plan was completed June 23, 2023.

Review on September 11, 2023, of the facility document, "Personnel Report," dated September 8, 2023, revealed PF1 had 13 unscheduled absences in less than 12 months over the past year. There was documentation PF1 was tardy August 29, 2023, September 1, 2023, September 2, 2023, and September 5, 2023. There was documentation PF1 signed and Acknowledged the Disciplinary Counseling on September 8, 2023.

Interview on September 11, 2023, with EMP3, at approximately 1230 confirmed PF1's Annual Performance Plan did not accurately reflect PF1's performance.

Review on September 11, 2023, of PF7, revealed PF7 was hired July 11, 2022. There was documentation PF7's Annual Performance Plan was signed and completed September 11, 2023, on the date of the survey.

Interview on September 11, 2023, with EMP7, at approximately 1245 confirmed the above findings.

2) Review on September 11, 2023, of the facility policy, "Attendance Policy - Human Resources Department," last reviewed May 2021 revealed "... I. Scope All LVHN employees except [Name of Lab Company] and where superseded by language contained in a collective bargaining agreement. ... II. Policy It is the policy of Lehigh Valley Health Network (LVHN) that all employees are expected to report to work on time as scheduled. An unscheduled absence or tardiness, even though the reason may be justified, is a disruption of services resulting in understaffing, increased costs and/or burdens to other employees. All employees are expected to maintain an acceptable record of attendance. The following process outlines the procedure in the event violations occur. III. Definitions ... Unscheduled absence - Defined as failure to be at work, when scheduled, for any reason. The definition of unscheduled absence for the purpose of this policy does Not include schedule time off utilizing the PTO bank, jury duty, military leave, bereavement leave, and time off covered by the Family Medical Leave Act (FMLA), regardless whether it's an intermittent or a continuous leave. ... One recorded unscheduled absence may exceed "one date" if the days off are for the same reason. For example, one unscheduled absence may be counted for several days or weeks of convalescence from illness or surgery. Clearance must be obtained through Employee Health Services Department (Employee Health) for any absence from work that results in physical restrictions upon return to work, or any absence of more than three (3) consecutive, full calendar days duration, or at the discretion of Employee Health. A note from the treating physician must be presented and clearance obtained through Employee Health prior to returning to work. ... Tardiness - The ATA system will be the official clock used for determining the exact time employees record hours. When an employee logs in after their scheduled start time, the employee shall be considered tardy. The period of time that elapses between recording start time and beginning productive time is also subject to be defined as tardy. Arrival and Departure Time - An employee is considered tardy is he or she reports to work six (6) minutes after the scheduled start time. Rolling 12 Month Period and Absences - There is a twelve (12)-month look back from the date of the most recent absence used to calculate an employee's number of absences. ... IV. Provisions ... C. Absenteeism Unscheduled absences - When attendance records indicate excessive unscheduled absences in a rolling twelve (12)-month period, the Disciplinary Process will be followed accordingly: 1. 4 unscheduled absences within 12 months may result in Confirmation of Counseling (original document sent to HR personnel file in HR). 2. 5 unscheduled absences within 12 months may result in Written Warning (original document sent to personnel filed in HR). 3. 7 unscheduled absences within 12 months may result in Final Written Warning or Suspension by Department Manager with concurrence from appropriate Vice President, or designee, and HR representative (original document sent to personnel file in HR). 4. 9 unscheduled absences within 12 months may result in Discharge by Department Manager, with approval of Senior Vice President or designee, and review with HR Representative (original documents sent to personnel file in HR). ... V. Procedure ... C. Employee attendance shall be monitored by the Department Manager on a regular basis in order to identify violations. D. The number of unscheduled absences, as well as improvements during the previous twelve (12) months shall be noted on the annual performance review and taken into consideration in determining a merit increase as per HR Policy Merit Pay Increases. ... M. Manage Responsibilities: 1. Review attendance concerns and communicate attendance expectations to employees. 2. Monitor attendance in a fair and consistent manner. 3. Address attendance concerns in a timely manner in accordance with policy with the goal of encouraging the employee to take steps necessary to correct the attendance problem and prevent further disciplinary action. 4. Absenteeism leading to disciplinary measures, in combination with employees past twelve (12)-month disciplinary record, will warrant an escalation of the discipline up to and including termination of employment. ..."

Review on September 11, 2023, of the facility document, "Personnel Report," dated September 8, 2023, revealed PF1 had 13 unscheduled absences in less than one year. There was documentation PF1 was tardy August 29, 2023, September 1, 2023, September 2, 2023, and September 5, 2023. There was documentation PF1 signed and Acknowledged the Disciplinary Counseling on September 8, 2023.

Review on September 11, 2023, of PF1's HR file did not reveal the following documentation: Confirmation Counseling for four unscheduled absences within 12 months; Written Warning for five unscheduled absences within 12 months; Final Written Warning for seven unscheduled absences within 12 months; Suspension or Discharge by Department for nine unscheduled absences within 12 months.

Interview on September 11, 2023, with EMP7, at approximately 1230, confirmed PF1's HR file did not contain the above findings.

Interview on September 11, 2023, with EMP9, at approximately 1300 revealed PF1 contained no Employee Health Restrictions or return to work documentation. EMP9 revealed PF1's employee health file was unremarkable.

Interview on September 11, 2023, with EMP8, at approximately 1235, confirmed PF1 had not been disciplined for absenteeism prior to the incident with MR1 and the facility Attendance Policy was not followed.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure only dialysis nurses accessed dialysis catheters for one of one medical record reviewed (MR1).

Findings:

Review on September 11, 2023, of the facility policy, "Catheter - Dialysis - Tunneled And Non-Tunneled - Patient Care Services," last reviewed April 2018 revealed "...I. Key Points: ... Catheter Site Care/Dressing Change 1. Catheter sites should be evaluated at every dialysis treatment by the dialysis nurse and evaluated at least once every shift on the nursing unit for evidence of catheter related complication by gentle palpation of the insertion site through the intact dressing and document. ... Accessing/Capping Catheter 1. The catheter(s) utilized for hemodialysis should not be used for IV's or IV medications unless there is no alternative IV site and an order is obtained from the nephrologist. ... LVH-P: Dialysis catheter access is limited to Dialysis nurses and providers. ... C. Administration Of Fluids And Medication ... Procedure: C.1. Initiating IV/IV Medication/Blood Products LVH-P: Only Dialysis Nurses and providers may access catheters ... C.2. Terminating IV/IV Medication/Blood Product LVH-P: Only dialysis nurses and providers may access catheters. ... D. Blood Sampling LVH-P: Only dialysis nurses and providers may access catheters. ..."

Review on September 11, 2023, of MR1, revealed the patient was admitted to the facility on August 24, 2023, with complaint of fall, syncope, and palpitations. MR1 was diagnosed with atrial fibrillation with rapid ventricular response and was admitted to telemetry. MR1 had a medical history of End Stage Renal Disease (ESRD) and started Hemodialysis on August 7, 2023, via temporary dialysis catheter.

Continued review of MR1 revealed a nurses note dated and timed September 2, 2023, 1040. There was nursing documentation MR1's spouse alerted nursing the patient had labored breathing and was not answering her. There was nursing documentation the registered nurse went to the patient's room and found MR1 staring straight ahead and not responding to stimuli, including sternal rub. There was documentation the patient's pupils were sluggish and an RRT was called. There was documentation the patient had right arm, leg, and facial tremors present. There was documentation bilateral eyes deviated to right side. There was documentation a Stroke Alert was called and the patient was taken to CT scan. There was nursing documentation a Tele-Neurology consult was completed, medications were administered, the patient was intubated, and was transferred to a tertiary care facility via Medivac on September 2, 2023, at approximately 1400.

Continued review of MR1 revealed physician documentation dated and timed September 2, 2023, at 1123. There was physician documentation the physician responded to the RRT called for MR1. There was documentation upon the physician's arrival the patient was twitching on the right side of his mouth, eyes were open but unresponsive. There was documentation a STAT CT scan of the head without contrast was ordered and Stoke Tele-Neurologist was consulted.

Continued review of MR1 revealed a CT scan of the head dated and timed September 2, 2023 from 1113 to 1122. There was documentation the CT scan impression was acute infarction in the right middle cerebral artery with questionable punctate hyperdensity in the anterior aspect of the right Sylvania fissure which could reflect embolus/thrombus verses atherosclerotic plaque and hypodensity along the bilateral cerebral sulci and within and along the superior sagittal sinus. No mass was identified on prior imagine suggesting a ruptured dermoid. There was documentation findings could be related to recent intravenous access/injection.

Continued review of MR1 revealed a Tele-stroke consult completed September 2, 2023, at 1122. There was physician documentation MR1 became unresponsive with right mouth twitching approximately five minutes after the patient was given a saline flush through his dialysis catheter. There was physician documentation the CT of the head demonstrated what appeared to be venous air emboli. There was physician documentation MR1 appeared to have diffuse dysfunction secondary to the air emboli. There was physician documentation MR1 should be transferred to a tertiary facility neuro ICU for further care and workup.

Continued review of MR1 revealed there was documentation MR1 received dialysis on September 1, 2023. There was also documentation PF1 administered medications and cared for MR1 on September 1, 2023. There was also documentation PF1 reviewed MR1's central line.

Interview on September 13, 2023, with PF1, at approximately 1030 revealed PF1 had cared for the patient on September 1, 2023. PF1 confirmed s/he recalled the patient receiving dialysis on September 1, 2023. PF1 explained s/he arrived late to work on September 2, 2023, at approximately 0800. PF1 revealed s/he read their patient assignment charts prior to providing care. PF1 revealed MR1 needed a sodium phosphate intravenous infusion on September 2, 2023, at approximately 1000. PF1 revealed s/he went to MR1's room to infuse the sodium phosphate around 1024. PF1 revealed s/he flushed MR1's dialysis catheter, realized afterwards it was a dialysis catheter and immediately alerted a registered nurse.

Interview on September 13, 2023, with PF2, at approximately 1230 revealed PF2 cared for MR1 on September 2, 2023. PF2 confirmed PF1 reported to PF2 s/he had flushed MR1's dialysis catheter. PF2 revealed they immediately went to check on the patient and called and reported the incident to the hospitalist, dialysis nurse, and nephrologist. PF2 confirmed at approximately 1040 MR1's spouse alerted the nurses MR1 was not responsive. PF2 confirmed they assessed MR1, called an RRT. PF2 stated a CT scan was ordered for MR1 and PF2 escorted MR1 to the CT scan. PF2 confirmed a Tele-Neurology Consult was completed and the Tele-neurologist reported to the provider and patient's spouse the CT scan showed a probable air emboli and MR1 would need to be transferred to a tertiary care facility.

Review on September 12, 2023, of PF1 revealed PF1 had completed the required training and education for central lines and hemodialysis catheters prior to the event.

Interview on September 1, 2023, with EMP1, at approximately 1100 confirmed all of the above findings.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure nursing staff documented facts regarding an event for one of one medical record reviewed (MR1).

Findings:

Review on September 11, 2023, of the facility policy, "Patient Safety Reporting - Administrative," last reviewed April 7, 2022, revealed "... II. Purpose: A. To create a standardized mechanism for identifying, reporting, investigating, trending and resolving incidents. B. To educate providers and patients/families concerning the many aspects of patient safety. ... Serious Event - An event, occurrence, or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in unanticipated injury to the patient requiring the delivery of additional health care services. ... IV. Procedure: ... e. Document clear, concise facts regarding the event itself in the patient's medical record. Document direct quotes of the patient; do not make assumptions. The Medical Record is to reflect the objective facts relating to the patient event. 1) No references to the completion of a Patient Safety Report are to be included in the Medical Record. ..."

Review on September 11, 2023, of the facility Event Log from August 1 to present revealed an event submitted for MR1. Review of the event revealed PF1 reported to an RN PF1 flushed MR1's dialysis catheter on September 2, 2023.

Review on September 11, 2023, of MR1 did not reveal documentation PF1 flushed MR1's dialysis catheter.

Interview on September 11, 2023, with EMP1, at approximately 1330, confirmed the above findings.