HospitalInspections.org

This Condition is not met as evidenced by:

Based on the systemic nature of the standards-level and condition level deficiencies related to Patient Rights, and Nursing services, the facility failed to substantially comply with this condition.

The findings were:

These following standards were cited and showed a systemic nature of non-compliance with the Conditions of Participation as follows:

482.12, Tag A043
The documentation reviewed revealed no evidence the Governing Body was aware about the psychiatric pediatric patients being treated on the inpatient pediatric medical unit from January 2017 through October 2019.

482.13, Tag A115
The documentation reviewed revealed the facility failed to provide a safe setting for psychiatric pediatric patients and inpatient pediatric medical patients.

482.13(c)(2), Tag A144
The documentation reviewed revealed the facility failed to provide a safe setting for psychiatric pediatric patients and inpatient pediatric medical patients.

482.13(f), Tag A0194
The documentation reviewed revealed the facility failed to ensure staff were trained in the application and monitoring of physical restraints

482.21(e)(1),(e)(2),(e)(5), Tag A309
The documentation reviewed revealed the faciltiy failed to inform the Governing Body of the ongoing treatment of psychiatric pediatric patient on the inpatient pediatric medical unit.

482.23(b), Tag A392
The facility failed to ensure pediatric staff were immediately available to provide specialized care on the pediatric medical unit.

482.23(b)(5), Tag A397
The facility failed to ensure staff had specialized training to care for psychiatric pediatric patient treated on the inpatient pediatric medical unit.


cross reference with:
482.12 - Condition - Governing Body
482.13 Patient Rights
482.13(c)(2) Patient Rights: Care in a Safe Setting
482.13(f) Patient Rights: Restraint and Seclusion
482.21(e)(1), (e)(2),(e)(3) QAPI Executive Responsiblities
482.23(b) Staffing and Delivery of Care
482.23(b)(5) Patient Care Assignments

This CONDITION is not met as evidenced by:

Based on the systemic nature of the standard-level deficiency related to Patient Rights, the facility failed to comply with this condition:

Findings include:

These following standards was cited and show a systemic nature of non-compliance with regards to Patient Rights as follows:


(482.13(c)(2), Tag-0144)
The documentation reviewed during the survey provided evidence the facility failed to provide a safe setting for the care of pediatric behavioral health patients

(482.13(f), Tag 0194)
The documentation reviewed during the survey provided evidence the facility failed to provide trained personnel for the care of pediatric patients with a psychiatric diagnosis.


Cross Reference:
482.12 - Condition - Governing Body
482.13(c)(2) Patient Rights: Care in a Safe Setting
482.13(f) Patient Rights: Restraint and Seclusion

Based on observation, review of facility documents, review of facility policies, review of medical records (MR) and interviews with staff (EMP), it was determined the facility failed to ensure the care provided to pediatric psychiatric patients and pediatric medical inpatients, was provided in a safe setting.

Findings include:

Review on November 8, 2019, of facility document "Department of Nursing Pediatrics Unit Structure Standards" revealed "... B. Utilization of Unit, 1. To provide individualized care to pediatric patients who require continuous medical and nursing intervention ... The Pediatric Unit serves the medical/nursing needs of children from the newborn period to 18 years of age for any pediatric diagnosis requiring hospitalization ..."

Review on January 7, 2020, of faciltiy document "Patient Rights and Responsibilities," reviewed November 19, 2019, revealed, " ... Patient has the right ... to receive care in a safe setting ... "

Review on January 10, 2020, of facility policy "Patient Rights and Responsibilities," revised September 15, 2015, revealed, "... The right to good quality care and high professional standards that are continually maintained and reviewed. Patients have the right to know if this hospital has relationships with outside parties that may influences their treatment and care ... The right to expect good management techniques to be implemented within the hospital, the provision of care in an environment that promotes patient safety, and the avoidance of unnecessary delays and personal discomfort."

Review on January 7, 2020, of facility document revealed that total number of pediatric patients on the inpatient unit from January 1, 2017, through November 16, 2019, was 2,944 patients which included 96 pediatric patients with primary psychiatric diagnoses.

Observation on November 8, 2019, at 10:00 AM of the Pediatric Unit revealed a secured access inpatient pediatric unit located on the 1st floor of the Buerger Building. This was a 15 bed unit with a patient census of five patients, and staffing of three registered nurse and one mental health technician. Additional staffing on the unit was a 1:1 staff for one 12 year old psychiatric pediatric patient and 2:1 staffing for another 12 year old psychiatric pediatric patient. The ages of the other pediatric patients with medical diagnosis were 20 days, 22 days, and 2.5 months. Two pediatric hospitalists were available on the unit. At the time of the observation, the unit was equipped as a medical-surgical unit with the specialty equipment necessary to care for the medical-surgical pediatric patient. The safety and environment of the unit was not designed to care for the special needs and behaviors of a pediatric patient with a primary psychiatric diagnosis.

Review on November 8, 2019, of MR1 revealed physician documentation "History and Physical" dated October 20, 2019, "patient is a 12 year old girl coming in via EMS with caregiver from a residential treatment facility for evaluation of suicidal gestures and aggression ... Patient had impulsive suicidality and self-injurious behaviors which have increased in frequency since admission. She has been aggressive towards her peers and has made multiple suicide attempts, most of which has been this week ... Other than the patient's behavioral health issues she feels she has no medical complaints ... she was with a foster family, but was suicidal and aggressive/abusive with them, and the foster mother would not take her back because she fears for the other foster's [children] safety ... Based on the age of the patient coupled with the fact the 302 (involuntary psychiatric admission) was filed in Montgomery County, the patient cannot be transferred to Philadelphia Children's Response Center without a formal psychiatric evaluation. Patient will be admitted to the pediatric floor under the medical service pending this ... ."

Review on November 8, 2019, of MR2 revealed physician documentation "History and Physical" dated September 25, 2019, "Patient is a 12 year old male with a history of post traumatic syndrome, enuresis and disruptive mood presents to the ED from [name of facility], 302 filed for increased aggression behavior over the past few days ... Patient reported to have kicked a co-resident in the head with great impact leading to a concussion. He was also noted to assault a co-resident by aggressively pushing his head while drinking from a water fountain ... Disposition: Admitted to 1B (pediatric unit) for observation pending social worker placement at residential facility ... Crisis and involved could not find inpatient bed today ... Patient admitted to Pediatrics pending psychiatric placement. Patient has no external injury, hemodynamically stable, medically cleared for psychiatric evaluation .. "

Review of facility document dated October 19, 2019, to November 2, 2019, revealed the following:

1."9/30/2019 [MR2]: 2:50 PM Crisis patient admitted with a history of violence and aggression. Patient requested to telephone cousin, rejected by RN as cousin unknown to RN, possible trigger to patient. Patient made aware of reasoning why [he] was not permitted. Started yelling and cursing, ran out into hallway with 1:1 punching wall, turning over equipment. Patient spitting throughout episode."

2."10/19/2019-[MR2]: 7:49 PM Patient became violent at nurses station, unable to be redirected, refused to return to room started throwing items off of nurses station towards nurses and ancillary staff and fish tank. Team 99 called (aggressive patient code). Slow response form security only one security guard appeared after 5 minutes nursing and ancillary staff were kicked, punched."

3."10/19/2019-[MR2]: 10:13 PM Patient at nursing station. Became increasingly agitated toward RN ' s and began throwing objects at staff. RNs attempted to redirect without success. Team 99 was called immediately. While waiting for response, patient attempted to elope locked unit and became physical with RNs and Care Associate. 1 security guard responded after 3 minutes. Someone had opened a locked door and patient attempted to run, the security guard was able to apprehend (no use of restraint) patient and bring him back to locked unit."

4."10/20/2019-[MR2]: Patient became increasingly agitated and throwing objects at nurse. He was unable to be redirected. Team 99 was called and 1 security officer arrived about 4 minutes later. A second Team 99 was called for more support."

5 "11/2/2019- [MR1]: 1:03 PM, RN attempted to call Team 99 using extension 777, rand 7 times no answer-hung up and recalled someone answered. By that time [patient was back in room and staff was attempting to put patient in restraints without proper assistance in timely manner. RN was kicked in the chest by patient "

6."11/3/2019-[MR3]: Patient on 1:1 confined to room sue to aggressive behavior, ran out into hallway swinging call bell. RN, MD and resident attempted to escort patient back to room. Staff kicked, punched and hit by patient. Team 99 called ..."

7."11/4/2019-[MR1]: patient chased 1:1 Clinical Associate out of room while swinging call bell that she pulled from wall at the Clinical Associate. Team 99 called and patient was returned to her room by staff."

Interview on November 8, 2019, at 9:45 AM with EMP1 confirmed the facility currently had two pediatric patients with psychiatric diagnosis admitted to the inpatient medical pediatric unit. Continued interview with EMP1 confirmed the facility's ED doesn't have psychiatric bays available to hold patients waiting for appropriate placement for continued care, and confirmed the rooms on the pediatric unit are not "psych safe." Further interview confirmed pediatric behavioral health patients were on "continuous 1:1 care." When [MR1] escaped from the room [they] were placed on 2:1 care."

Interview on November 8, 2019, at 10:20 AM with EMP2 confirmed MR1 was currently in four point restraints and on a 2:1 observation watch because the patient ran out of the room while on a 1:1 watch and locked [themselves] in the bathroom. When staff were able to gain access to the bathroom, patient was attempting suicide by wrapping a cord around the neck. Continued interview with EMP2 confirmed the unit was not safe when psychiatric patients are admitted to the floor with medical patients. EMP2 confirmed the psychiatric patients were loud, cursed often, and were "violent with staff and destructive with equipment ...[ MR1] broke the sink facet." Further interview with EMP2 confirmed parents of the medical pediatric patients "were afraid to leave their babies alone to get a shower" asking the staff "is it safe to leave my baby?" Continued interview with EMP2 confirmed staff did not have training in treating psychiatric patients other than CPI (de-escalation) and yearly restraint training.

Interview with EMP1 on January 7, 2020, at 2:15 PM confirmed 96 pediatric psychiatric patients were treated on the inpatient pediatric medical unit. Further interview with EMP1 confirmed the inpatient pediatric medical unit did not include psychiatric pediatric patients in the scope of services.

cross reference:
482.12 - Condition - Governing Body
482.13 - Condition - Patient Rights
482.13(f) Patient Rights: Restraint and Seclusion
482.21(e)(1), (e)(2),(e)(3) QAPI Executive Responsiblities
482.23(b) Staffing and Delivery of Care
482.23(b)(5) Patient Care Assignments

Based on review of faciltiy documents, personnel files (PF) and interview with staff (EMP) it was determined the facility failed to ensure staff were trained to safely implement the use of physical restraints in 6 of 18 PFs reviewed (PF1, PF2, PF3, PF4, PF5 and PF7).

Findings include:


Review on Janaury 6, 2020, of facility document "Participant Workbook for Nonviolent Crisis Intervention, Foundation Course," revealed no documentation or training directives for the application and monitoring of physical restraints or seclusion.

Review on November 8, 2019, and Jnauary 6, 2020, of facility policy "Restraint and Seclusion" reviewed May 17, 2019, revealed "Purpose: ... During treatment of specific conditions or when certain behaviors are exhibited, caregivers use a variety of interventions to promote patient safety and decrease the risk for interruption of medical healing or behaviors which may cause harm to patients, staff and others ... Education, Training and Competence: 1. Appropriate staff participate in education, training, and assessment of competence on the use of restraint ... 2.(a) Safe application and use of restraints and seclusion how to recognize and respond to signs of physical or psychological stress ... f. Monitoring the physical and psychological well-being of the patient in restraints ..."

Review on Janaury 6, 2020, of MR1, MR2, MR6, MR7, MR8 and MR9 revealed these patients were treated with 4-point locked physical restraints or seclusion for the management of aggressive behavior towards themselves and staff.

Review on Janaury 6, 2020, of PF1, PF2, PF3, PF4, PF5 and PF7, revealed the staff in these PFs were not trained in the application and monitoring of physical restraint or seclusion. Further review revealed PF1, PF2, PF3, PF4, PF5 and PF7, received CPI (Crisis Prevention Intervention) deescalation training.

Interview on January 7, 2020, at approximately 12:30 PM with EMP10 confirmed the staff in PF1, PF2, PF3, PF4, PF5 and PF7 received CPI.

Interview on Janaury 7, 2020, at approximately 1:00 PM with EMP4 staff in PF1, PF2, PF3, PF4, PF5 and PF7did not receive training in the application and monitoring of physical restraints and seclusion.


cross reference:
482.12 - Condition - Governing Body
482.13 - Condition - Patient Rights
482.13(c)(2) Patient Rights: Care in a Safe Setting
482.21(e)(1), (e)(2),(e)(3) QAPI Executive Responsiblities
482.23(b) Staffing and Delivery of Care
482.23(b)(5) Patient Care Assignments

Based on review of facility documents and interview with staff (EMP), it was determined the faciltiy failed to provide documentation to the Governing Body that psychiatric pediatric patients were treated on the inpatient pediatric medical unit from January 2017 through November 2019.

Findings include:

Review on January 7, 2020, of facility document "Amended and Restated Bylaws of Abington Memorial Hospital," Amended May 1, 2015, September 24, 2019, revealed, " ... Article III. Board of Trustees ... 3.2 Board Role ... 3.2.1. The Board shall have responsibility for overall policy and strategic clinical direction of the Hospital with a focus on performance improvement and patient safety, licensure and accreditation, compliance ... The President and other senior management shall have responsibility for the day-to-day direction and management of the Hospital ... "

Review on January 7, 2020, of facility document revealed that total number of pediatric psychiatric patients being treated on the inpatient pediatric medical unit from January 1, 2017, through November 16, 2019, was 2,944 patients, which included 96 pediatric patients with primary psychiatric diagnoses.

Review on January 6, and 7, 2020, of facility documents that included Medical Executive meeting minutes, AMH/LH (Abington Memorial Hospital/Lansdale Hospital) Board Committee on Patient Safety and Quality meeting minutes, dated January 2019 through September 2019 and Emergency Department meeting minutes dated April 2019 through September 2019 revealed no documentation that psychiatric pediatric patients were being treated on the inpatient pediatric medical unit.

Interview with EMP1 on January 7, 2020, at 2 PM confirmed the total number of psychiatric pediatric patients that were treated on the inpatient pediatric medical unit from January 1, 2017, through November 16, 2019, was 96 pediatric patients with primary psychiatric diagnoses. Further interview with EMP1 confirmed there was no documentation in the above facility documents that psychiatric pediatric patients were treated on the medical pediatric unit between January 2019 and September 2019.

cross reference with:
482.12 - Condition - Governing Body
482.13 Patient Rights
482.13(c)(2) Patient Rights: Care in a Safe Setting
482.13(f) Patient Rights: Restraint and Seclusion
482.23(b) Staffing and Delivery of Care
482.23(b)(5) Patient Care Assignments

Based on review of facility documents and interview with staff it was determined the facility failed to ensure trained pediatric staff were immediately available to provide bedside nursing care for psychiatric pediatric patients trested on the pediatric medical-surgical unit.

Findings include:

Review on January 7, 2020, of facility document "Abington Memorial Hospital, Department of Nursing, Unit Structure Standards," revised June 2018, revealed "Overview ... the Pediatric Unit is an inpatient unit in operation 24 hours per day, seven days per week. Staffing is maintained on a 24 hour basis with consideration focused on changing acuity and or census ... ANA Principles For Nurse Staffing, There are 9 principles of staffing by the ANA (American Nurses Association) outlined below in 3 categories. Abington Memorial Hospital is committed to assuring our practices are aligned with these principles. There are many critical factors when considering staffing ... 1. Patient Care Unit Related, appropriate staffing based on patient care needs, average daily census and staffing ratios, consideration is given to unit functions when determining staff ... Number of patients, intensity of patients ... unit layout and technology, experience of the staff, patient related: age and ability ... Staff related: Clinical Components are determined based on specific needs of the patient, RNs are supported by nursing leadership and the board level, clinical experts are available at all times ... experience with patient population, level of RN experience, education and certification ...""

Review on January 7, 2020, of a facility document that listed safety occurrences on the pediatric unit revealed "10/30/19, 10:19 AM. staff felt unsafe in staffing situation. One pediatric nurse administering blood to a 2 year old and other pediatric RN caring for patient with respiratory distress and doing their best to admit the multiple patients coming from the ETC (Emergency Trauma Center). Medical-Surgical nurse with no pediatric experience caring for all 3 1:1 patients, one of which had a team 99 called earlier in the shift and was put in restraints at 11:40 PM and given PRN (administered as needed) meds. At the same time, the patient flow center, and ETC attempting to get another patient to the floor after they had been told the unsafe situation staff was currently dealing with. the situation was made more chaotic and unsafe with multiple phone calls when staff said they would get patient up to the floor as soon as they safely could. By: [name of employee] 10/30/2019, 10:55 AM, no extra pediatric staff available to come in. Will follow up with flow center and ETC."

On January 7, 2020, at approximately 11:30 AM documents were requested to EMP5 for the follow-up for the evaluation of staffing needs and follow-up with ETC and the Patient Flow Center. None provided.

Interview on November 8, 2019, at approximately 11:00 AM with EMP7 confirmed the psychiatric pediatric patients treated on the unit often "act out" and staff are scared because they do not have specialized training to address their behaviors. Further interview with EMP7 confirmed families of other patients on the unit have expressed concern about the safety of their child when they witness the psychiatric patients acting aggressively towards staff or throwing equipment on the unit.

Interview on November 8, 2019, at 10:20 AM with EMP1 confirmed pediatric patients were held in the ETC waiting to be transferred to the Pediatric Unit. Further interview confirmed staffing was not at a safe level based on the acuity of the medical patients and the aggressive behavior of the pediatric psychiatric patients.

Interview on January 7, 2020, with EMP5 confirmed staffing was appropriate for patient acuity and census.

Interview on Janaury 6, 2020, at approximately 2:00 PM with EMP4 confirmed the three (3) 1:1 patients were psychiatric pediatric patients. Further interview confirmed staff receive deescalation and restraint training but do not receive training in the care and management of psychiatric pediatric patients.


cross reference with:
482.12 - Condition - Governing Body
482.13 Patient Rights
482.13(c)(2) Patient Rights: Care in a Safe Setting
482.13(f) Patient Rights: Restraint and Seclusion
482.21(e)(1), (e)(2),(e)(3) QAPI Executive Responsiblities
482.23(b)(5) Patient Care Assignments

Based on review of facility documents, review of personnel files (PF), and interview with staff (EMP), it was determined the facility failed to ensure staff had specialized training to care for psychiatric pediatric patients that were treated on the inpatient medical pediatric nursing unit for 6 of 18 personnel files reviewed (PF1, PF2, PF3, PF4, PF5 and, PF7).

Findings include:

Review on November 8, 2019, of facility document "Department of Nursing Pediatrics Unit Structure Standards" revealed "... B. Utilization of Unit, 1. To provide individualized care to pediatric patients who require continuous medical and nursing intervention ... The Pediatric Unit serves the medical/nursing needs of children from the newborn period to 18 years of age for any pediatric diagnosis requiring hospitalization ..."

Review on January 7, 2020, of facility document revealed that total number of pediatric patients on the inpatient unit from January 1, 2017, through November 16, 2019, was 2,944 patients that included 96 pediatric patients with primary psychiatric diagnoses.

Review on January 7, 2020, of facility document "Nursing Service Orientation Packet Psychiatric Unit," revealed it contained objectives and/or performance skills that included psychiatric diagnosis of : ... Major Depression, Bipolar Disorder ... schizophrenia, Dual Diagnosis ... OCD, Border line, Sociopathic, ... Paranoia, Anxiety , Suicidality, Akaesthesias, Depression ... ".

Review on January 7, 2020, of "RN Initial Compentency Assessment," for staff assigned to the medical Pediatric Unit revealed it did not contain any objectives and/or performance skills that included psychiatric diagnoses.

Review of January 7, 2020 of "RN Initial Compentency Assessment Addendum RN Maternal/Child," revealed it did not contain objectives and/or performance skills that included psychiatric diagnoses for the pediatric psychiatric patient.

Review on January 7, 2020, of PF1, PF2, PF3, PF4, PF5 and PF7 revealed these licensed staff were assigned and provided care on the inpatient medical pediatric unit that included care for psychiatric pediatric patients that were treated on the inpatient medical pediatric unit.

Interview with EMP4 on January 7, 2020, at 1:00 PM confirmed the staff in PF1, PF2, PF3, PF4, PF5 and PF7 were assigned and provided care to the inpatient medical pediatric unit and did not receive psychiatric training for the care and management of psychiatric pediatric patients on this unit.

cross reference with:
482.12 - Condition - Governing Body
482.13 - Condition Patient Rights
482.13(c)(2) Patient Rights: Care in a Safe Setting
482.13(f) Patient Rights: Restraint and Seclusion
482.21(e)(1), (e)(2),(e)(3) QAPI Executive Responsiblities
482.23(b) Staffing and Delivery of Care