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Based on the seriousness of the noncompliance, the facility failed to substantially comply with this condition.

Based on the systemic nature of the standard-level deficiencies related to emergency services, the facility staff failed to comply with this condition.

These following standards were cited and show a systemic nature of noncompliance with regards to emergency services as follows:

Based on review of facility documents, medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure the safety of a patient by failing to provide nursing supervision by placing the patient in an unstaffed area of the Emergency Department (ED) in one of one medical records reviewed (MR1), by failing to follow adopted policies to ensure that STAT EKGs were obtained immediately and/or within ten minutes in seven of 26 medical records (MR6, MR7, MR8, MR9, MR10, MR11, and MR13), by failing to ensure that STAT Troponin levels were collected immediately in seven of 26 medical records (MR1, MR7, MR8, MR9, MR10, MR12, and MR13), by failing to ensure that the NIH (National Institutes of Health) Stroke Scale was completed in three of 26 medical records (MR3, MR9, and MR12), by failing to ensure that Neurological Assessments were completed in five of 26 medical records (MR3, MR4, MR9, MR12, and MR13), by failing to ensure consistent documentation of Cardiac Monitoring in 10 of 26 medical records (MR1, MR2, MR9, MR11, MR12, MR13, MR14, MR19, MR20, and MR24), by failing to implement continuous pulse oximetry in one of 26 medical records (MR2), by failing to titrate oxygen levels per parameter ordered in one of 26 medical records (MR3), and by failing to triage patients in a timely manner in two of 26 medical records (MR7 and MR10).

Findings include:

Review of "An Act Relating to the practice of professional nursing; ...(Title amended Dec. 17,1959, P.L. 1888, No. 689) The General Assembly of the Commonwealth of Pennsylvania hereby enacts as follows: Section 1. Short Title.--This act shall be known and may be cited as 'The Professional Nursing Law.' (1 amended Dec. 20, 1985, P.L. 409, No. 109) Section 2. Definitions.--When used in this act, the following words and phrases shall have the following meanings unless the context provides otherwise: (1) The 'Practice of Professional Nursing' means diagnosing and treating human responses to actual or potential health problems through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimens as prescribed by a licensed physician or dentist. ... ."



Review of facility document, "Three Hundred (300) Commonly Used Medical Abbreviations-A Primer," revealed that STAT means immediately.

UPMC Altoona ... Category: Special Procedures ... Subject: National Institute of Health Stroke Scale ... Category Number: T-Nursing 13 policy and procedure dated November 2021. "...VI.Policy: ... The NIHSS is completed in the ED on arrival of the patient and scored within 15 minutes in the electronic health record ... ."

UPMC Altoona Standard Practice ... ED T 2.1 ... Section: Emergency Department ... Subject: Triage in the Emergency Department policy and procedure dated July 20, 2022. " Purpose: To provide an organized, systematic, method of assessing and prioritizing patient care to ensure immediate care of acute patients. Patients presenting to the ED shall be evaluated and triaged to determine the nature of their presenting complaints, their condition, and their priority for receiving an examination by a physician. ... 4. When the department has an immediate ED bed available the patient should be taken immediately from the waiting room to an Emergency Department bed. To expedite patient flow, triage may be completed in the patient room rather than in the triage room. Determination of which bed will be based on the patient initial complaint. A Registered Nurse will determine the appropriate ESI level and patients will be monitored according to the specific ESI level. ... . "

Review of ED Policy entitled "Emergency Department Code STEMI-Pre-Hospital Alert Policy", dated July 20, 2022, revealed an attached document entitled "ED Flowchart for Patients at Low/Intermediate Risk for Acute Coronary Syndrome", which stated "... Pt. arrives with complaint of chest pain or other symptoms of ACS ... Immediately obtain 12 lead EKG and present to Physician or APP. EKG must be done and read within 10 minutes of pt. arrival. Place a copy of EKG on chart and transmit to EMR ... Walk-in patients completed in protocol room. Ambulance pt's completed at bedside. ... ."

UPMC Altoona Standard of Practice ... Subject:: 12 Lead EKG process policy and procedure dated July 20, 2022. " I. Purpose: To establish process for obtaining, reviewing and documenting 12 lead EKG in the Emergency Department. II. Responsible Levels of Personnel: This policy applies to all UPMC Altoona employees acting on behalf of UPMC Altoona in the Emergency Department. III. Standard of Practice: The hospital provides care, treatment, and services for each patient according to their plan for care, treatment, and services. IV. Procedure: a. Patients arriving to the ED seeking treatment who require a diagnostic 12 lead EKG based on chief complaint and triage criteria will undergo that EKG within 10 minutes of check in to the ED. b. The 12 lead EKG will be completed by trained personnel in the Emergency Department. c. The 12 lead EKG will be electronically uploaded to MUSE AND 3 hard copies will be printed. ... d. 1 hard copy will be presented to the ED MD immediately after completion for interpretation and signature to include date and time. ... . "

UPMC Standard of Practice ... M 34 ... Section: ED, Critical Care Nursing, Medical/Surgical Nursing ... Subject: Utilization of Cardiac Monitors to UPMC Altoona policy and procedure dated December 31, 2022. " Purpose: It is the policy of UPMC Altoona that patients whose clinical condition warrants the need for cardiac monitoring will utilize the type of monitoring necessary as is detailed per unit standard and/or contained within a Patient Care Policy and Procedure and/or per physician order. These conditions include but are not limited to: a. Patients whose clinical condition puts the patient at risk for developing arrhythmias and/or patients being evaluated for arrhythmias. ... Standard of Practice: The hospital provides care, treatment, and services for each patient according to the plan of care, treatment, and services. Procedure: A. Arrhythmia Monitoring 1. On admission to the designated area, the patient who is ordered cardiac rhythm monitoring will be connected to the bedside monitor or to telemetry, as is appropriate to the unit monitoring system. ... 4. Once attached to the monitor, an initial rhythm strip is to be printed and mounted in the patient's medical record. Do not fanfold rhythm strips (fan folded strips are unable to be scanned into the electronic health record). Information to be documented will include the patient's name, room number, date, time, monitoring leads, rates, and an interpretation of the rhythm. Rhythm strips are to be printed/mounted and documented on admission, when arrhythmias are present, when there is a change in the patient condition, and when a serious event occurs. Rhythm strips are to be printed/mounted within every shift as per unit protocol and should be read and documented every 4 hours in electronic health record. ... . "

1. Review of MR1 revealed the patient presented to the ED with chest pain on November 2, 2022 at 10:48 AM. The patient was moved from Triage room 02 at 11:02 AM into the waiting room until 4:26 PM, when the patient was then moved to an unstaffed and unmonitored area, Bed 16 (Plum), where they remained until they were moved to ED bed 5 at 8:15 PM.

Further review of MR1 ED Evaluation Note dated November 2, 2022 at 11:01 AM revealed that the patient was to be admitted for further workup and also due to their cardiac history and was then moved to an unstaffed and unmonitored section of the Emergency Room because there were no staffed monitored beds available. It was then noted that at 6:30 PM the patient still remained in an unmonitored unstaffed section of the Emergency Room.

Further review of MR1 Direct Admission Attending Communication dated November 2, 2022 at 3:44 PM, revealed that the patient remained in the waiting room due to staffing shortages and that they were not accepting responsibility for the patient at that time.

Further review of MR1 revealed an order for a Cardiac Monitor dated November 2, 2022 at 9:32 PM. There was no documented evidence of cardiac rhythm strips printed/mounted in the medical record (MR1).

Further review of MR1 revealed that an order for STAT Troponin was placed on November 2, 2022 at 11:58 AM and was collected at 1:22 PM. Another order for a STAT Troponin was placed at 2:47 PM and was collected at 4:41 PM.

Interview with EMP2 on January 20, 2023 at approximately 2:00 PM confirmed the findings.

2. Review of MR2 revealed that the patient presented to the Emergency Department with chest pain and shortness of breath on September 25, 2022 at 5:13 PM. The patient remained in the waiting room until September 26, 2022 at 1:39 PM, when they were moved back to ED Bed 43.

Further review of MR2 revealed that Cardiac Monitoring was ordered STAT on September 25, 2022 at 5:18 PM. Continuous Pulse Oximetry was also ordered on September 25, 2022 at 5:18 PM.

Further review of MR2 revealed no documented evidence that the patient had cardiac monitoring or continuous pulse oximetry per physician order.

Interview with (EMP9) via telephone on November 9, 2022 at approximately 10:00 AM confirmed that the patient did not receive cardiac monitoring or continous pulse oximetry due to having been placed in the waiting room.

3. Review of MR3 revealed that the patient arrived to the ED on December 29, 2022 at 2:18 PM.
Further review of MR3 revealed that an order was placed for the NIH Stroke Scale on December 29, 2022 at 6:32 PM. The first NIH Stroke Scale was not documented until December 29, 2022 at 7:04 PM.
Further review of MR3 revealed an order for Neurological Checks on December 29, 2022 at 6:32 PM. There was no documented evidence in the medical record of neurological assessments completed every four hours after December 30, 2022 at 4:00 AM.
Further review of MR3 revealed an order for Oxygen (O2) on December 29, 2022 at 6:32 PM. The order was for nasal cannula daily in order to maintain the SPO2 equal to or over 94%. The patient's O2 sat dropped to 90% on December 30, 2022 at 12:00 AM and 88% at 4:00 AM. There was no documented evidence in the medical record that the patient was placed on O2 via nasal cannula.
Interview with EMP3 on January 27, 2023, confirmed the findings.
4. Review of MR4 revealed an order for Neurological Checks on November 2, 2022 at 2:52 AM. There was no documented evidence that neurological assessments were completed every four hours following the order until November 2, 2022 at 8:54 AM.
Interview with EMP3 on January 27, 2023, confirmed the findings.
5. Review of MR6 revealed the patient presented with chest pain on November 2, 2022, at 7:54 AM.

Further review of MR6 revealed an order for an EKG 12 Lead STAT, dated November 2, 2022, at 8:05 AM. Review of the EKG noted a date/time stamp as November 2, 2022, 8:31:28.

Interview with EMP3 on January 27, 2023, confirmed the findings.

6. Review of MR7 revealed the patient presented on December 19, 2022, at 3:39 AM, with nausea and abdominal pain. Ambulance trip sheet documentation timed 3:41 AM stated after finding a wheelchair, patient was transferred from the litter to the wheelchair and per the staff, the patient was placed in the waiting room.

Further review of MR7 revealed the patient was not triaged until 7:16 AM.

Further review of MR7 revealed an order for Troponin I Level, STAT, dated December 19, 2022, 7:28 AM, was not sent to the lab until 11:15 AM.

Further review of MR7 revealed an order for EKG 12 Lead, STAT, dated December 19, 2022, 8:37 AM. Review of the EKG noted a date/time stamp as December 19, 2022, 8:54:31.

Interview with EMP3, on January 27, 2023, confirmed the findings.

7. Review of MR8 revealed the patient presented with chest pain on December 19, 2022, at 4:21 AM. Documentation in the medical record stated that patient had been in the waiting room for about 4.5 hours without labwork drawn.

Further review of MR8 revealed an order for Troponin I Level, STAT, dated December 19, 2022, 5:28 AM.

Interview with EMP3, on January 27, 2023, revealed the the Troponin was not received in the lab until 9:18 AM, and confirmed this was a delay of approximately four hours.

Further review of MR8 revealed an order was placed for EKG 12 Lead STAT, dated December 19, 2022, 5:28 AM. Review of the EKG noted a date/time stamp as December 19, 2022, 6:27:24.

Further review of MR8 revealed an additional order for EKG 12 Lead, STAT, dated December 19, 2022, 10:09 AM. Review of the EKG noted a date/time stamp as December 19, 2022, 10:33:35.

Interview with EMP3, on January 27, 2023, confirmed the findings.

8. Review of MR9 revealed the patient presented with weakness on December 19, 2022, at 1:55 PM.

Further review of MR9 revealed an order for Troponin I Level, STAT, dated December 19, 2022, 2:11 PM, received in the lab at 3:03 PM.

Further review of MR9 revealed an order for EKG 12 Lead, STAT, dated December 19, 2022, 2:12 PM. Review of the EKG noted a date/time stamp as December 19, 2022, 14:51:33.

Further review of MR9 revealed an order for Cardiac Monitor, dated December 19, 2022, 5:55 PM. There was no documented evidence of cardiac rhythms while the patient was in the ED.

Further review of MR9 revealed an order for Neurological Checks, dated December 19, 2022, 6:24 PM. There was no documented evidence that neurological checks were completed while the patient was in the ED.

Further review of MR9 revealed an order for NIH Stroke Scale, dated December 19, 2022, 6:24 PM. There was no documented evidence that NIH Stroke Scales were completed while the patient was in the ED.

Interview with EMP3, on January 27, 2023, confirmed the findings.

9. Review of MR10 revealed the patient presented with chest pain on November 24, 2022, at 8:36 PM and was triaged at 9:30 PM.

Further review of the MR10 revealed an order for EKG 12 Lead, STAT, dated November 24, 2022, 9:40 PM. Review of the EKG date/time stamped November 24, 2022, 22:31:24.

Further review of MR10 revealed that the provider advocated for patient to be given a room in the ED and to have an EKG immediately performed, but there was no staff available to perform the EKG and patient was administratively sent back into the waiting room.

Further review of MR10 revealed an order for Troponin I Level, STAT, dated November 24, 2022, 9:40 PM, sent to the lab at 10:54 PM.

Interview with EMP3, on January 27, 2023, confirmed the findings.

10. Review of MR11 revealed the patient presented with chest pain on December 19, 2022, at 5:04 AM.

Further review of MR11 revealed an order for EKG 12 Lead, STAT, dated December 19, 2022, 5:49 AM. Review of the EKG noted a date/time stamp as December 19, 2022, 06:17: 43.

Further review of MR11 revealed an order for Cardiac Monitor, dated December 19, 2022, 11:58 AM.

Interview with EMP3 on January 27, 2023, confirmed that there was no documented evidence of cardiac rhythms while the patient was in the ED, and confirmed all other findings.

11. Review of MR12 revealed the patient presented with intermittent numbness/weakness to the right arm and right foot on November 5, 2022, at 7:31 AM.

Further review of MR11 revealed an order for Troponin I Level, STAT, dated November 5, 2022, 9:01 AM, however, was not collected until 10:53 AM.

Further review of MR11 revealed an order for Cardiac Monitor, dated November 5, 2022, 9:01 AM, however, revealed no documented evidence of a cardiac rhythm while patient was in the ED.

Interview with EMP3 on January 27, 2023, confirmed the findings.

Further review of MR11 revealed an order for Neurological Checks and NIH Stroke Scale, dated November 5, 2022, at 9:01 AM.

Interview with EMP2, on January 27, 2023, revealed that neuro checks are to be completed every four hours, and NIH Scales are to be completed every shift. EMP2 also confirmed there was no documented evidence of NIH scales on November 5, 2022 evening shift and on nightshift into November 6, 2022, and confirmed that there was no documented evidence of neurological checks every four hours while the patient was in the ED.

12. Review of MR13 revealed the patient presented on November 7, 2022, at 9:41 PM.

Further review of MR13 revealed an order for Cardiac Monitoring, STAT, dated November 7, 2022, 9:49 PM.

Interview with EMP3 on January 27, 2023, confirmed there was no documented evidence of cardiac rhythm while patient was in the ED.

Further review of MR13 revealed an order for EKG 12 Lead, STAT, dated November 7, 2022, 9:49 PM. Review of the EKG noted a date/time stamp of November 7, 2022, 22:20:53.

Interview with EMP3 on January 27, 2023, confirmed the findings.

Review of MR13 revealed an order for Neurological Checks, dated November 8, 2022, 3:23 AM.

Interview with EMP3 on January 27, 2023, confirmed that there was no documented evidence of neurological checks while the patient was in the ED.

Further review of MR13 revealed an order for Troponin I Level, STAT, dated November 8, 2022, 3:23 AM.

Interview with EMP3 on January 27, 2023, confirmed the level was not collected until 6:26 AM.

13. Review of MR14 revealed the patient presented with chest pain and shortness of breath, on November 2, 2022, at 6:54 AM.

Further review of MR14 revealed an order for cardiac monitor on November 2, 2022 at 2:02 PM.

Further review of MR14 failed to reveal documented evidence of cardiac rhythms following order for cardiac monitor while the patient was in the ED.

Interview with EMP3 on January 27, 2023, confirmed the findings.


14. Review of MR19 revealed the patient arrived to the ED on November 2, 2022 at 1:33 PM.

Further review of MR19 revealed an order for a cardiac monitor on November 2, 2022 at 2:01 PM.

Interview with EMP3 on January 31, 2023 at approximately 9:30 AM confirmed that there was no documented evidence of a cardiac strip or rhythm.
15. Review of MR20 revealed the patient arrived to the ED on November 2, 2022 at 5:29 PM and went to an inpatient unit on November 3, 2022 at 1:52 AM.
Further review of MR20 revealed an order for a cardiac monitor on November 2, 2022 at 5:44 PM.
Further review of MR20 revealed no documented evidence of cardiac monitoring while the patient was in the ED per order.
Interview with EMP2 on January 23, 2022 at approximately 3:00 PM revealed that rhythm strips are not run on every ED patient. The rhythm should be documented on the I View sheet or it should be documented by the nurse that the patient was on a monitor.
Interview with EMP3 on January 31, 2023 at approximately 9:35 AM confirmed the findings.
16. Review of MR24 revealed a physician order for cardiac monitor on November 1, 2022, at 11:49 PM.

Further review of MR24 failed to reveal documented evidence of mounted cardiac rhythm strips during the patient's stay in the emergency department.

Interview with EMP2 on January 23, 2023, at 1:40 PM confirmed the above findings in MR24 and also stated that they have never mounted telemetry strips in the medical record of ED patients. EMP2 confirmed that the actual heart rhythm of the patient should be documented in the patients' medical record.