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The Physical Environment Condition was found to be out of compliance during a Life Safety survey completed on March 1, 2023. Further details are outlined in the Division of Life Safety survey Event ID HWDD21.

Based on review of facility policy, observation, and staff (EMP) interview, it was determined the facility failed to ensure the Emergency Department was free of clutter; there were devices available for patients to call for assistance; there were sufficient handwashing stations; and the electrical power was supplied in a safe manner.

Findings include:

Review on March 1, 2023, of facility policy "Environment of Care (EOC) Program," approved April 2022, revealed " Purpose: The purpose of the EOC Program is to provide a multi-disciplinary forum and framework in which to identify and manage environment of care issues at Susquehanna Health thus promoting a safe environment for patients, visitors and staff. ...Responsibility: ...Department Directors are responsible for the safety performance of all service partners in their service areas. Department Directors ensure that safe practices and conditions are observed throughout their areas of responsibility. ..."

Review on March 1, 2023, of facility policy "Hand Hygiene," dated October 27, 2022, revealed "...Purpose Effective hand hygiene removes transient microorganisms, dirt and organic material from the hands and decreases the risk of cross contamination to patients, patient care equipment and the environment. ...V. Procedures A. Indications for hand hygiene In most cases, either an alcohol based hand sanitizer or handwashing with soap and water may be used for hand hygiene. ...VI. Organizational Responsibility To promote compliance with these requirements alcohol hand sanitizer dispensers, sinks and other means for hand hygiene have been installed, as appropriate, in corridors and rooms throughout UPMC facilities. ..."

Tour of the emergency department (ED) and interview with EMP1, EMP4 and EMP28 on February 28, 2022, at approximately 1000, revealed clutter (EKG machine, bed/stretcher and two wheelchairs) narrowing the path of egress in the east corridor near the trauma offices in the main ED. Tour of the waiting room revealed a section on the southwest end with an overflow treatment area. The area was up against the outside window area and contained ten stretchers in areas partitioned off with the use of portable room dividers. Observation revealed there were no devices available for patients to call for assistance, there was one hand sanitizing station in the walled off area behind the patient care area and two patient bathrooms in the same area. Additionally, electrical power was supplied to the area through a web of extension cords with one cord taped down across the walkway.

Interview with EMP28 at the time of the tour confirmed the corridor clutter and stated, "storage is an issue throughout the ED". EMP28 confirmed the availability of only one hand sanitizing station and the sinks in the patient bathrooms were the only means for hand hygiene for staff. EMP28 revealed the facility has tap bells for use but they "walk off " so they are given only to confused patients. EMP28 further confirmed electrical cord taped across the walkway and that the area was supplied by multiple extension cords from main outlets in the support pillars to power equipment in the overflow area.