HospitalInspections.org

Based on a tour of the Geropsych Unit, review of facility documents and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to identify equipment and/or areas in need of repair by failing to incorporate routine and preventative maintenance and testing activities related to lighting in their Performance Excellence Plan.

Findings Include:

Review of Conemaugh Memorial Medical Center ... PolicyStat ID: 1574404 ... Last Reviewed: 12/2015 ... Policy Area: Organization-General ... Performance Excellence Plan ... revealed, "... STRUCTURE ... G. Operating Units Operating Units for the purposes of performance excellence and service excellence are defined as Departments, Divisions, Service Lines or other functional business units. Such Operating Units are subject to change from time to time. Operating Unit Leaders, whether they be Department Directors and Chairpersons or others, are responsible for continuous monitoring of activities that support the organization's vision and appropriate metric development for services that are provided at MMC. Operating Unit Leaders, along with their Physician Leader counterparts where appropriate, are responsible for determining PE opportunities, utilizing the strategic plan for the line of sight performance excellence opportunities, selecting appropriate measures and benchmarks, and setting appropriate targets. 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 specific results are discussed at staff meetings and displayed on unit Quality Boards. Based on the magnitude of the issues, it may be resolved at the departmental level and/or be channeled to PEC. ... J. Environmental Safety and Emergency Preparedness Committee ... The Environmental Safety and Emergency Preparedness Committee will report pertinent issues and their resolution through quarterly and annual reviews. In addition, this Committee is charged with plan development for Interim Life Safety, Emergency Preparedness, and compliance with State and Federal Regulations, and TJC standards. The Safety Officer is responsible for overseeing the Safety Program and is the point person for OSHA and DOH building safety. ... ." (jb)

Review of DEPARTMENTAL POLICY AND PROCEDURE MANUAL ... Facility Operations, CONEMAUGH HEALTH SYSTEM JOHNSTOWN CAMPUS, Good Samaritan Medical Center/Memorial Medical Center. Policy Manual TITLE: Support Mission of the Facility Operations Department dated November 2012, revealed, "PURPOSE: We will support Conemaugh Health Systems in the provision of healthcare by ensuring facilities, equipment and utilities as defined by Facility Operations Department policies, procedure, guidelines and forms as maintained. ... PHILOSOPHY By measurement, evaluation and assessment of our performance, we will seek areas where there are opportunities for improvement of Facility Operations functions. ... ."

Review of Section: Managing Risk ... EC.01.01.01 EP3 ... Subject: Safety Management Plan dated January 2016 revealed, "Utility Systems Management Plan 2016 ... revealed, "Safety Management Plan 2016 I. SCOPE: The Safety Management Plan describes the programs used to manage the Safety Management Program to reduce the risk of injury for patients, staff and visitors for Conemaugh Memorial Medical Center. Safety risks may arise from the structure of the physical environment, from the performance of everyday tasks, or may be related to situations beyond the organization's control. Safety incidents are most often accidental. ... II. FUNDAMENTALS ... B. Safe working conditions and practices are established by using knowledge of safety principle to educate staff, design appropriate equipment and supplies, and monitor the implementation of the processes and policies. C. Safety is dynamic. Regular evaluation of the environment for work practices and hazards is required to maintain a current relevant Safety Management Program. The program should change as needed to respond to identify risks, hazards and regulatory compliance issues. III. OBJECTIVES The Objectives for the Safety Management Program are developed from information gathered during routine and special risk assessment activities, annual evaluation of the previous year's program activities, performance measures, incident and injury reports and environmental tours. The Objectives for this plan are: To provide a safe environment for patients, visitors, students, physicians, employees, and volunteers ... To investigate and trend safety-related incidents/hazards to assure that appropriate actions are taken to reduce/eliminate any similar recurrences. ... To provide a safe environment for all users of equipment and utilities by establishing and monitoring an effective safety program in each area ... V. PERFORMANCE ACTIVITIES ... The performance measure for the Safety Management Program is: 80% staff knowledge of how to report a safety incident 85% of identified deficiencies on environmental tours are corrected and documented as completed within 45 days Trending of employee and patient injuries and incidents Staff knowledge questioned during code drills ... V. PROCESSES OF THE MANAGING SAFETY RISKS ... Safety Risk Assessment-EC.02.01.01 EP1 ... This assessment process identifies safety risks associated with environment of care. Risks are identified from internal sources, such as ongoing monitoring of the environment, result of root cause analyses, results of annual proactive risk assessment of high-risk processes ... and from credible external sources such as Sentinel Event Alerts. The risk assessment is used to evaluate the impact of care on the ability of the organization to perform clinical and business activities. The impact may include disruption of normal functions or injury to individuals. The assessment will evaluate the risk from a variety of functions, including structure of the environment, from the performance of everyday tasks, falls, exposures, MRI, Lasers, etc. ... Use of Risk Assessment Results-EC.02.01.01.EP3 ... The actions may be creating new programs, processes, procedures, or training programs. Monitoring programs may be developed to assure the risks have been controlled to achieve the lowest potential for adverse impact on the safety and security of patients, staff, and visitors. ... Environmental Tours-EC.04.01.01 EP12-14 ... The EOC Chairperson/Safety Officer and designees conducts and coordinates a team approach to regular environmental tours to identify and evaluate environmental deficiencies, hazards, and unsafe practices, security deficiencies, hazardous materials and wastes practices, fire safety problems, medical gas equipment issues, access to utility system elements, staff knowledge and other issues. Environmental tours are conducted at locations approved by the Chair. The tours are conducted on a monthly basis with patient care (clinical) areas scheduled every six months and non-patient care (non-clinical) areas scheduled on an annual basis. The manager or designee of the department is sent the results of the environmental tour and is responsible for remediation of deficiencies. The EOC/Chairperson/Safety Officer, in coordination with the manager or designee is responsible for initiating appropriate action to address findings of the environmental tour process. This is accomplished through work orders for the deficiencies that need to be fixed from a physical nature, if within budget constraints. The EOC Chairperson/Safety Officer provides the EOC Committee with monthly reports on activities related to the environmental tour process. Evaluating the Management Plan-EC.04.01.01 EP15 On an annual basis, the EOC Chairperson/Safety Officer evaluates the scope, objectives, performance, and effectiveness of the Plan to manage the safety risks to the staff, visitors, and patients. ... ."
1) During the tour of the Geropsych Unit (GS8) with EMP5, at 10:15 AM, all patient rooms, GS8801, GS8807, GS8802, GS8811, GS8804, GS8813, GS8829, GS8821, GS8833, GS8835 and GS8837, had no working night lights.

Interview was conducted with EMP5 who confirmed the above findings.

2) Review of Good Samaritan 8 Geriatric Inpatient Unit Behavioral Health Medicine Environment of Care Checklist dated July 18, 2016, failed to reveal any items observed/ monitored that related to lighting of any kind.

3) Review of Environment of Care Committee meeting minutes dated March 10, 2016, April 27, 2016, June 23, 2016, and July 28, 2016, failed to reveal any discussion of night lights on any nursing unit within the facility.

An interview was conducted with EMP7 on August 16, 2016, at approximately 10:15 AM. "... I did not know the wall lights were not operational. They should work, I was not aware. The night lights are not part of our Safety Rounds. You will not see any discussion in the Environmental Care Committee meeting minutes about the night lights. They are not on any sort of list to be checked on a routine basis."

3) A review of Conemaugh Memorial Performance Steering Committee Meeting minutes dated September 2015, through June 2016, was conducted. Documentation revealed topics of discussion that included but not limited to, Patient Safety, Environmental Safety, Emergency Preparedness Quality Improvement and Behavioral Medicine Environment of Care Checklist.

Further review of meeting minutes revealed approval of the Behavioral Medicine Environment of Care Checklist and lighting was not included on the checklist.

4) A review of Conemaugh Memorial Performance Excellence Committee Meeting minutes dated June 2015, through April 20, 2016, revealed that approval of the Behavioral Medicine Environment of Care Checklist and lighting was not included on the checklist.

Based on a tour of the Geropsych Unit, review of facility documents and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to maintain a safe environment by failing to identify that the night-lighting in patient rooms was not operational.

Findings Include:

Review of Conemaugh Memorial Medical Center ... PolicyStat ID: 1574433 ... Last Reviewed: 12/2015 ... Policy Area: Organization-Clinical ... Patient Safety Plan ..." revealed, "STATEMENT OF POLICY 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 responsibility of each employee, physician, student, and volunteer to promote safety and prevent injury. ... To this end, the Board of Trustees has endorsed a patient safety program that included the following elements: Commitment of the Board and leadership to foster a culture in which patient safety is paramount and all individuals (employees, physicians, volunteers, and students) work diligently to ensure safe patient care. ... ." (jb)

Review of DEPARTMENTAL POLICY AND PROCEDURE MANUAL ... Facility Operations, CONEMAUGH HEALTH SYSTEM JOHNSTOWN CAMPUS, Good Samaritan Medical Center/Memorial Medical Center. Policy Manual TITLE: Support Mission of the Facility Operations Department dated November 2012, revealed, "PURPOSE: We will support Conemaugh Health Systems in the provision of healthcare by ensuring facilities, equipment and utilities as defined by Facility Operations Department policies, procedure, guidelines and forms as maintained. ... PHILOSOPHY By measurement, evaluation and assessment of our performance, we will seek areas where there are opportunities for improvement of Facility Operations functions. ... ."

Review of Section: Managing Risk ... EC.01.01.01 EP3 ... Subject: Safety Management Plan dated January 2016 revealed, "Utility Systems Management Plan 2016 ... revealed, "Safety Management Plan 2016 I. SCOPE: The Safety Management Plan describes the programs used to manage the Safety Management Program to reduce the risk of injury for patients, staff and visitors for Conemaugh Memorial Medical Center. Safety risks may arise from the structure of the physical environment, from the performance of everyday tasks, or may be related to situations beyond the organization's control. Safety incidents are most often accidental. ... II. FUNDAMENTALS ... B. Safe working conditions and practices are established by using knowledge of safety principle to educate staff, design appropriate equipment and supplies, and monitor the implementation of the processes and policies. C. Safety is dynamic. Regular evaluation of the environment for work practices and hazards is required to maintain a current relevant Safety Management Program. The program should change as needed to respond to identify risks, hazards and regulatory compliance issues. III. OBJECTIVES The Objectives for the Safety Management Program are developed from information gathered during routine and special risk assessment activities, annual evaluation of the previous year's program activities, performance measures, incident and injury reports and environmental tours. The Objectives for this plan are: To provide a safe environment for patients, visitors, students, physicians, employees, and volunteers ... To investigate and trend safety-related incidents/hazards to assure that appropriate actions are taken to reduce/eliminate any similar recurrences. ... To provide a safe environment for all users of equipment and utilities by establishing and monitoring an effective safety program in each area ... V. PERFORMANCE ACTIVITIES ... The performance measure for the Safety Management Program is: 80% staff knowledge of how to report a safety incident 85% of identified deficiencies on environmental tours are corrected and documented as completed within 45 days Trending of employee and patient injuries and incidents Staff knowledge questioned during code drills ... V. PROCESSES OF THE MANAGING SAFETY RISKS ... Safety Risk Assessment-EC.02.01.01 EP1 ... This assessment process identifies safety risks associated with environment of care. Risks are identified from internal sources, such as ongoing monitoring of the environment, result of root cause analyses, results of annual proactive risk assessment of high-risk processes ... and from credible external sources such as Sentinel Event Alerts. The risk assessment is used to evaluate the impact of care on the ability of the organization to perform clinical and business activities. The impact may include disruption of normal functions or injury to individuals. The assessment will evaluate the risk from a variety of functions, including structure of the environment, from the performance of everyday tasks, falls, exposures, MRI, Lasers, etc. ... Use of Risk Assessment Results-EC.02.01.01.EP3 ... The actions may be creating new programs, processes, procedures, or training programs. Monitoring programs may be developed to assure the risks have been controlled to achieve the lowest potential for adverse impact on the safety and security of patients, staff, and visitors. ... Environmental Tours-EC.04.01.01 EP12-14 ... The EOC Chairperson/Safety Officer and designees conducts and coordinates a team approach to regular environmental tours to identify and evaluate environmental deficiencies, hazards, and unsafe practices, security deficiencies, hazardous materials and wastes practices, fire safety problems, medical gas equipment issues, access to utility system elements, staff knowledge and other issues. Environmental tours are conducted at locations approved by the Chair. The tours are conducted on a monthly basis with patient care (clinical) areas scheduled every six months and non-patient care (non-clinical) areas scheduled on an annual basis. The manager or designee of the department is sent the results of the environmental tour and is responsible for remediation of deficiencies. The EOC/Chairperson/Safety Officer, in coordination with the manager or designee is responsible for initiating appropriate action to address findings of the environmental tour process. This is accomplished through work orders for the deficiencies that need to be fixed from a physical nature, if within budget constraints. The EOC Chairperson/Safety Officer provides the EOC Committee with monthly reports on activities related to the environmental tour process. Evaluating the Management Plan-EC.04.01.01 EP15 On an annual basis, the EOC Chairperson/Safety Officer evaluates the scope, objectives, performance, and effectiveness of the Plan to manage the safety risks to the staff, visitors, and patients. ... ."
Review of Conemaugh Memorial Medical Center ... PolicyStat ID: 1734666 ... Last Reviewed: 06/2015 ... Policy Area: Nursing ... Fall Prevention Policy ... revealed, "... STATEMENT of POLICY Patient safety is an ongoing responsibility of all staff. ... Points of Emphasis: 1. Staff will institute basic fall precautions when any patient first enters the room ... Fall Prevention Measures for all patients regardless of risk: ... Orient to environment ... Make sure that night-lights are turned on in patient rooms during evening rounds ... ."
1) During the tour of the Geropsych Unit (GS8) with EMP5, at 10:15 AM, all patient rooms, GS8801, GS8807, GS8802, GS8811, GS8804, GS8813, GS8829, GS8821, GS8833, GS8835 and GS8837, had no working night lights.

Interview was conducted with EMP5 who confirmed the above findings.

An interview was conducted with EMP4 during the tour on August 16, 2016, at approximately 9:45 AM. "Not sure what this is , I think it's a vent of some sort. Maybe they are night lights that come on automatically. ... We get a lot of confused patients on this Unit. ... The lights in the hall are dimmed at night. ... Sometimes we leave the light on in the bathroom with the door cracked."

An interview was conducted with EMP6 during the tour on August 16, 2016, at approximately 10:15 AM. "They are night light fixtures, and I believe that they should be on twenty-four seven."

An interview was conducted with EMP8 during the tour while testing the vented wall fixture on August 16, 2016, at approximately 10:30 AM. "Looks like the incandescent bulb has burned out. There's no power to the light fixture."

2) Review of Good Samaritan 8 Geriatric Inpatient Unit Behavioral Health Medicine Environment of Care Checklist dated July 18, 2016, failed to reveal any items observed/ monitored that related to lighting of any kind.

3) Review of Environment of Care Committee meeting minutes dated March 10, 2016, April 27, 2016, June 23, 2016, and July 28, 2016, failed to reveal any discussion of night lights on any nursing unit within the facility.

An interview was conducted with EMP7 on August 16, 2016, at approximately 10:15 AM. "... I did not know the wall lights were not operational. They should work, I was not aware. The night lights are not part of our Safety Rounds. You will not see any discussion in the Environmental Care Committee meeting minutes about the night lights. They are not on any sort of list to be checked on a routine basis."