HospitalInspections.org

Based on review of facility documents and personnel files (PF), and staff interview (EMP), it was determined the facility failed to ensure compliance with the Child Protective Services Law and any regulations promulgated there under by the Department of Public Welfare for two of 13 PF reviewed (PF2 and PF5).

Findings include:

Review of 23 Pa. CSA ?6344 reveals, "For the purposes of this subsection, an applicant may submit a copy of the information required under paragraphs (1) and (2) with an application for employment. Administrators shall maintain a copy of the required information and shall require applicants to produce the original document prior to employment..."

Review of the November 2008 "Notice to Facilities on Required Employment Clearances" revealed, "To assure compliance with the requirements of the Law, facilities must... -Retain a copy of each of the background clearances and notate that the original documents have been reviewed..."

On July 24, 2014, at approximately 10:00 AM, review of facility policy, "Required Clearances, Certifications & Licensure Policy #0067" dated July 2014 revealed, "...Employees must provide Human Resources with an original copy of their current clearances, certifications and/or licenses upon hire. A copy of the original document may be provided only if Human Resources has viewed the original document and initialed the copy...5. The following charts denote the required clearances, licensure and/or certifications for each corresponding work group...All Staff DPW ChildLine Clearance...FBI Background Check...PA State Background Check..."

1. Review of PF2, on July 22, 2014, at approximately 1:00 PM revealed a copy of the Child Abuse clearance record without any notation of who viewed the original or if the original was viewed.

During an interview on July 22, 2014, at approximately 2:30 PM, EMP3 confirmed the above findings.

2. Review of PF5, on July 22, 2014, at approximately 2:00 PM revealed that there was no child abuse clearance documentation.

During an interview on July 22, 2014, at approximately 2:30 PM, EMP3 confirmed that there was no child abuse background clearance for PF5.

Based on review of facility documents and credential files (CF) and staff interview (EMP), it was determined the facility failed to ensure candidates for re-credentialing met all criteria as defined in the Medical Staff Bylaws for seven of 16 credential files reviewed (CF1, CF7, CF8, CF12, CF14, CF15 and CF16).

Findings include:

Review of the facility "Bylaws Rules and Regulations The Medical Staff of The Children's Home of Pittsburgh" revised April 21, 2014, revealed, "Section 7: Procedure for Reappointment...Subsection (D). Factors to be Considered. (i) Each recommendation concerning the reappointment of a Medical Staff member or a change in staff category, where applicable, shall be based upon: (i) such member's professional ethics and his/her ability to perform the essential functions of his/her profession with or without reasonable accommodation; (ii) his/her attendance at Medical Staff meetings and participation staff affairs; (iii) his/her compliance with the Hospital bylaws, policies and directives and these Bylaws, rules and Regulations; (iv) his/her cooperation with Hospital personnel; (v) his/her use of the Hospital's facilities for his/her patients, his/her cooperation and relations with other practitioners, clinical assistants and house staff, and his/her general attitude toward patients, the Hospital and the public; (vi) his/her competence and clinical judgment in the treatment of patients as evidenced by: number and appropriateness of admissions; mortality/morbidity rates for patients in his/her care (e.g. infectious disease rates); length of hospital stay for patients; participation in patient care conferences; and, frequency and appropriate utilization of ancillary services..."

1. On July 23, 2014, at approximately 11:30 AM review of CF1 revealed the physician was recredentialed for a period of two years in July 2014. Review of the "Reappointment Activity Summary" for June 2013 - July 2014 revealed no data was available related to meeting attendance, medical record completion or clinical patient care.

On July 24, 2014, at approximately 9:30 AM EMP1 stated, "[MD] hasn't seen any patients here."

2. On July 23, 2014, at approximately 12:15 PM review of CF7 revealed the physician was recredentialed in October 2013 for a period of two years. Review of the "Reappointment Activity Summary" for November 2011 - October 2013 revealed no data was available related to meeting attendance, medical record completion or clinical patient care.

On July 24, 2014, at approximately 2:00 PM EMP10 confirmed the physician of CF7 has been on staff since 2008 with no evidence of in-house activity.

3. On July 23, 2014, at approximately 12:30 PM review of CF8 revealed the physician was recredentialed in August 2013. Review of the "Reappointment Activity Summary" for August 2011 - August 2013 revealed no data was available related to meeting attendance, medical record completion or clinical patient care.

On July 24, 2014, at approximately 2:00 PM EMP10 confirmed the physician of CF8 was part of a larger physician group and may provide on call services to the facility. However, currently there was no way to capture that data.

4. On July 23, 2014, at approximately 1:30 PM review of CF12 revealed the physician was recredentialed in June 2013. Review of the "Reappointment Activity Summary" for May 2012 - June 2013 revealed no data was available related to meeting attendance, medical record completion or clinical patient care.

On July 24, 2014, at approximately 2:00 PM EMP10 confirmed there was no activity data for this physician.

5. On July 23, 2014, at approximately 1:50 PM review of CF14 revealed the physician was recredentialed in November 2013. Review of the "Reappointment Activity Summary" for November 2011 - November 2013 revealed no data was available related to meeting attendance, medical record completion or clinical patient care.

On July 24, 2014, at approximately 2:00 PM EMP10 confirmed the physician to CF14 had been on staff since 2010 with no record of providing services in house. EMP10 stated, "This is a consulting physician and part of a larger group so we may just not be capturing any activity data. However, we will be using this service much more in the future."

6. On July 23, 2014, at approximately 2:00 PM review of CF15 revealed the physician was recredentialed in May 2014. Review of the "Reappointment Activity Summary" for June 2012 - June 2014 revealed no data was available related to meeting attendance, medical record completion or clinical patient care.

On July 24, 2014, at approximately 9:30 AM EMP10 confirmed the above findings.

7. On July 23 2014, at approximately 2:15 PM review of CF16 revealed the physician was recredentialed in January 2014. Review of the "Reappointment Activity Summary" for January 2012 - January 2014 revealed no data was available related to meeting attendance, medical record completion or clinical patient care.

On July 24, 2014, at approximately 2:00 PM EMP10 confirmed the physician to CF16 has been on staff for almost 30 years but has not attended a patient in the facility for at least 20 years.

Based on review of facility documents and employee interview (EMP), it was determined that the facility failed to established time frames for review of the grievance when follow up required more than the three business days per facility policy requirement.

Findings include:

Review of The Children's Home of Pittsburgh, "Complaint/Grievance Process" on July 22, 2014, at approximately 1:00 PM, revealed that the policy was revised on January 12, 2013, and stated, "...Complaint: A concern raised by (or on behalf of) a patient, client or visitor about the services or operations of The Children's Home...Grievance: A complaint becomes a grievance against The Children's Home by the parent/guardian of a patient being served by the hospital that is not resolved to the complainant's satisfaction with 24 hours and that is related to the care of the child...Grievance...1. If a complaint against The Children's Home by the parent/guardian of an patient being served by the hospital is not resolved to the complainant's satisfaction with 24 hours and it is related to the care of the patient, the complaint is now considered to be a grievance...3. A response will be provided in writing to the parent within three (3) business days and will include: The name of the hospital contact person; The steps taken on behalf of the patient to investigate the grievance; The results of the grievance process; and The date of completion..."

1. During an interview on July 22, 2014, at approximately 2:00 PM, EMP1 confirmed that facility policy for complaints and grievances does not include the stated number of days to follow-up a written response, when the hospital investigation is not completed within the policy required three business days.

Based on review of facility documents and employee interview (EMP), it was determined that the facility failed provide the patient with written notice of the results of the grievance process for four of four grievances reviewed, as per facility policy.

Findings include:

Review on July 22, 2014, of The Children's Home of Pittsburgh, policy, "Complaint/Grievance Process" revised on January 12, 2013, revealed, "...Complaint: A concern raised by (or on behalf of) a patient, client or visitor about the services or operations of The Children's Home...Grievance: A complaint becomes a grievance against The Children's Home by the parent/guardian of a patient being served by the hospital that is not resolved to the complainant's satisfaction with 24 hours and that is related to the care of the child...Grievance...1. If a complaint against The Children's Home by the parent/guardian of an patient being served by the hospital is not resolved to the complainant's satisfaction with 24 hours and it is related to the care of the patient, the complaint is now considered to be a grievance...3. A response will be provided in writing to the parent within three (3) business days and will include: The name of the hospital contact person, The steps taken on behalf of the patient to investigate the grievance, The results of the grievance process, and The date of completion..."

1. Review of a facility "Complaint and Investigation" report on July 22, 2014, at approximately 11:30 AM revealed a complaint dated December 16, 2013, and timed 1300. The complaint investigation indicated, "...This process took a few weeks due to the availability of witnesses to the incident...Resolved...12.30.13..." The letter to the complainant was dated January 2, 2014.

During an interview on July 22, 2014, at approximately 1:30 PM, EMP1 confirmed that the complainant [for the December 16, 2013 complaint] did not receive the letter with the results of the complaint investigation in three days as required by facility policy.

2. Review of a facility "Complaint and Investigation" report on July 22, 2014, at approximately 11:45 AM revealed a patient rights complaint dated June 20, 2014, and timed 5:00 PM. The letter to the complainant was dated June 26, 2014.

During an interview on July 22, 2014, at approximately 1:40 PM, EMP1 confirmed that the complainant [for the June 20, 2014 complaint] did not receive the letter with the results of the complaint investigation in three days as required by facility policy

3. Review of a facility "Complaint and Investigation" report on July 22, 2014, at approximately 11:50 AM revealed a complaint related to inadequate staffing, which was dated May 13, 2013, and timed 11:15 AM. The report indicated that the complaint was not resolved as of May, 13, 2013. A note documented on the report revealed, "...5/14/13...mom visits in evening and will be in on 5/15/13 to meet with me...5/16/13...Time 1:30 PM...Resolved..." There was no letter sent to the complainant.

During an interview on July 22, 2014, at approximately 1:45 PM, EMP1 confirmed that the complainant [for the complaint of May 13, 2013] did not receive the letter with the results of the complaint investigation as required by regulation and facility policy.

4. Review of a facility "Complaint and Investigation" report on July 23, 2014, at approximately 9:50 AM revealed a complaint related to staff communication, which was dated June 6, 2014, and timed 15:00. The report indicated that the complaint was not resolved until June 9, 2014. There was no letter sent to the complainant.

During an interview on July 23, 2014, at approximately 9:50 AM, EMP2 confirmed that the complainant [for the complaint of June 6, 2014] did not receive the letter with the results of the complaint investigation as required by regulation and facility policy.

Based on review of facility policy and medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure restraints were used only in accordance with a written order for one of one records reviewed (MR1).
Findings include:
Review of facility policy "Restraints" reviewed May 1, 2014, revealed, "...VIII. Physician's Orders: 1. Restraint is used based upon order of physician/nurse practitioner...8. If a restraint is discontinued prior to the expiration of the original order, a new order must be obtained to re-apply."
1. Review of MR1 revealed a physician order dated April 24, 2013, at 4:00 PM for bilateral arm restraints to be placed on the patient for no greater than 30 minutes. Nursing documentation at 6:30 PM indicated bilateral arm restraints were placed on the patient "for only a few minutes."
Additional nursing documentation at 7:15 PM indicated the patient was again agitated and placed in bilateral arm restraints. There was no documentation as to when the restraints were removed and there was no order for the re-application of restraints.
2. On July 22, 2014, at approximately 1:00 PM review of MR1 revealed a nursing note dated April 27, 2013 at 12:00 PM which indicated the patient's right arm was restrained for an unspecified period of time. There was no order for the right arm restraint.
3. A nursing note dated April 27, 2013, at 11:00 PM indicated the patients arms were restrained with splints for less than ten minutes. There was no physician order for the restraints.
4. On May 5, 2013 at 11:30 AM nursing staff documented the patient was in restraints for approximately one hour. However, there was continued documentation on the restraint flow sheet from 1:00 PM to 8:00 PM. There was no order for re-application of restraints at 1:00 PM.
5. Further review of MR1 revealed a nursing note dated May 8, 2013, at 9:00 PM which indicated the patient required restraints for approximately 1.5 hours. There was no physician order for the application of restraints at that time.
6. On May 9, 2013, at 9:15 AM there was a physician order to apply restraints for no greater than 30 minutes. Nursing documentation indicated the patient was restrained for 60 minutes.
7. On May 9, 2013, at 12:45 PM there was another order to apply restraints for no more than two hours. Nursing documentation indicated restraints were applied at 12:45 PM but there was no documentation as to when the restraints were removed.
8. Continued review of MR1 revealed a physician order dated May 14, 2013, at 12:45 PM to apply arm splints for no greater than two hours. Nursing documentation revealed arm splints were applied at 1:00 PM. There was no documentation as to when the restraints were removed.
9. There was a physician order dated May 18, 2013, at 12:45 PM for the use of restraints for a period of time no greater than two hours. Nursing documentation revealed the patient was placed in restraints at 1:00 PM. There was no documentation as to when the restraints were removed.
10. Review of nursing documentation dated May 27, 2013, at 7:00 AM revealed the patient of MR1 was in restraints at that time. There was no order for the use of restraints at that time or other documentation to indicate when or why the patient was placed in restraints.
11. Review of nursing documentation dated May 29, 2013, at 10:00 PM revealed, "...Pt. with intermittent episodes of increased agitation requiring RN to restrain." There was no physician order for application of restraints at that time.
On July 23, 2014, at approximately 9:00 AM EMP1 confirmed the above identified concerns related to use of restraints on this patient.

Based on review of facility policy and medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure orders for restraint use were not written as PRN.
Findings include:
Review of facility policy "Restraints" reviewed May 1, 2014, revealed, "...VIII. Physician's Orders...5. Orders can never be written as a PRN or as a standing order."
1. Review of MR1 on July 22, 2014, at approximately 2:30 PM revealed a nursing note dated May 27, 2013, at 7:00 AM which indicated the patient was in restraints at that time.
2. A physician order was written on May 27, 2013 at 7:15 AM which stated, "Please remove soft restraints (aka 'no-nos') now. But ok to use soft restraints for self-injurious behavior no greater than 2 consecutive hours."
On July 23, 2014, at approximately 9:00 AM EMP1 reviewed the above information and stated, "That looks like a PRN order."

Based on review of facility policy, medical record review (MR) and staff interview (EMP), it was determine the facility failed to ensure complete documentation for each episode of restraint use per facility policy for one of one medical records reviewed (MR1).

Findings include:

Review of facility policy "Restraints" reviewed May 1, 2014, revealed, "XIV. Documentation: The following will be included in the documentation of each episode of restraint. 1. The patient's behavior prior to restraint. 2. Interventions used and alternatives tried/or considered; identify least to most restrictive alternatives applied. 3. the rationale and justification for use. 4. Written orders; 5. The patient's response to use..."

1. On July 22, 2014, at approximately 1:00 PM review of MR1 revealed there was an order dated May 2, 2013, at 11:30 PM for the use of restraints. There was no nursing documentation related to the use of restraints at that time.

2. There was an order dated May 8, 2013, at 2:00 PM for the use of restraints for a period of time no greater than two hours. Nursing documentation indicated restraints were placed on the patient at 2:00 PM and removed at 4:00 PM. There was no indication why restraints were placed or the justification for discontinuation of restraints at that time.

3. There was an order dated May 14, 2013, at 8:10 AM for the use of restraints. There was no nursing documentation related to the use of restraints at that time.

4. There was an order dated May 14, 2013, at 2:00 PM for the use of restraints. There was no nursing documentation related to the use of restraints at that time.

5. Continued review of MR1 revealed an order dated May 15, 2013, at 12:15 PM for the use of restraints. There was no nursing documentation related to the use of restraints at that time.

On July 23, 2014, at approximately 9:00 AM EMP1 confirmed there was no documentation related to the use of restraints on the patient of MR1 as identified above.

Based on review of facility documents and employee interview (EMP), it was determined that the facility failed to develop a policy regarding the visitation rights that included the necessary or reasonable restriction or limitation and the reasons for the clinical restriction or limitation.

Findings include:

Review of facility policy on July 23, 2014, "Hospital Visitation" revised June 2013 revealed, "...Purpose To provide guidelines for visiting patients at the Pediatric specialty Hospital, the procedure for identification of visitors and access to the hospital...9) It is encouraged that if families or visitors of Hospital inpatients show signs of any active communicable infection (including siblings), they should refrain from visiting and exposing the infection to the patients in the hospital."

1. During an interview on July 23, 2014, at approximately 9:50 AM, EMP2 confirmed that the policy does not contain any restrictions or limitations that the hospital may need to place on visitation rights, such as visitors engaged inn disruptive, threatening, or violent behavior, or when the hospital is aware that there is an existing court order restricting contact to a particular individual, or when visitation may interfere with the care of other patients.

Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined the facility failed to include pertinent information related to an unusual event involving the care of the patient in one of two medical records (MR11)

Findings include:

1. On July 25, 2014, at approximately 9:45 AM review of a facility document revealed the patient of MR11 received an incorrect dose of medication on April 5, 2014.

2. On July 25, 2014, at approximately 10:25 AM review of MR11 revealed no documentation on April 5, 2014, or subsequent to that date related to the administration of an incorrect dose of medication.

During an interview on July 25, 2014, at approximately 10:35 AM EMP1 confirmed there was no documentation of the unusual event in MR11 and stated, "I think the error wasn't realized until after the patient had already been transferred [to an outside facility]. But she [nurse] should have still added a note about it [incorrect medication dose]."

3. On July 25, 2014, at approximately 11:30 AM review of facility policies "Documentation EMR" reviewed May 12, 2014, and "Reporting of Clinical Occurrences" reviewed October 7, 2013, revealed that neither policy contained instruction to the nursing staff on the documentation of unusual patient events in the medical record.

EMP2 confirmed the above information related to the facility policies at the time of discovery.