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Tag No.: A0115
Based on the seriousness of the non-compliance and the potential effect on patient outcome, the facility failed to substantially comply with this condition.
The findings were:
482.13 Tag A-0144
The information reviewed during the survey provided evidence the facility failed to ensure an emergency department patient telemetry alarm alert was audible and continuous resulting in a delay of staff intervention in one of one applicable medical record (MR1) reviewed.
A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP4, and EMP5) regarding the survey team's concerns related to Patient's Rights on December 22, 2021, at approximately 1430.
Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting
Tag No.: A0123
Based on review of facility policy and facility documentation and staff (EMP) interview, it was determined that the facility failed to ensure its grievance policy was followed by failing to send an interim letter within seven days of receipt of a grievance if the grievance could not be resolved within seven days for one of three grievances reviewed (MR23).
Findings include:
Review on December 22, 2021, of facility policy "Patient Complaints and Grievances - Resolution Process," last approved August 2019, revealed "Policy: It is the policy of UPMC Susquehanna to promptly investigate and resolve any patient's, or their legal representative's, complaint(s) or grievance(s) in a prompt and equitable manner. ...Procedure: ...G. ... All complainants will be notified within 7 days as to the steps being taken to resolve their grievance and that they will receive prompt written notification of the results following completion of the investigation. If the problem cannot be resolved within 7 days, an interim letter will be sent within this time frame to inform the complainant that the investigation may be prolonged, but we will respond in writing when the complaint investigation is completed/resolved. ..."
Review on December 22, 2021, of the facility documentation concerning the grievance filed on behalf of MR23 revealed EMP12 received a grievance letter on April 26, 2021. Documentation revealed EMP12 spoke with MR23's son (no date of conversation recorded) and EMP12 later received an additional ten-page grievance letter (no date of receipt). EMP12 forwarded the letter to OTH1 on May 20, 2021. A final grievance letter was sent on May 24, 2021.
Interview with EMP2 on December 22, 2021, at 1340, confirmed there were no dates of EMP12's conversation with MR23's son or the date of receipt of the second complaint letter. EMP2 confirmed there was no way to determine if the final grievance letter was sent in accordance with the time frame set forth in the facility's policy.
Tag No.: A0144
Based on review of facility policy, facility documentation and medical records (MR) and staff (EMP) interview, it was determined the facility failed to provide care in a safe setting by failing to ensure an emergency department (ED) patient telemetry alarm alert was audible and continuous resulting in a delay of staff intervention in one of one applicable medical record (MR1) reviewed.
Findings include:
Review on December 21, 2021, of facility policy "Patients' Notice and Bill of Rights and Responsibilities," dated January 4, 2021, revealed "... IV. Patient's Notice and Bill of Rights ... Staff and Environment You have a right to: 1. Receive respectful care given by competent personnel in a setting that: a. is safe and promotes your dignity, positive self image and comfort; ...Other Healthcare Services You have a right to: 1. Emergency procedures to be implemented without unnecessary delay. ..."
Review on December 21, 2021, of facility policy "Alarm Management," dated August 27, 2021, revealed "I. Policy...UPMC's management of alarms will address the following: 1. Clinically appropriate settings for alarm signals...II. Purpose The purpose of this policy is to provide information about alarm management. Clinical alarm systems are intended to alert caregivers of potential patient problems. If equipment and alarms are not properly managed, patient safety can be compromised. ..."
Review of MR1 on December 21, 2021, revealed MR1 was in the emergency department on telemetry awaiting transfer to a higher level of care. When EMP7 entered the patient's room on December 1, 2021, at approximately 0100, s/he found MR1 unresponsive in cardiac and respiratory arrest.
Interview with EMP7 on December 21, 2021, at 1300 revealed from 1900 on November 30, 2021, until 0100 on December 1, 2021, MR1 was on telemetry in the privacy mode. When s/he entered MR1's room on December 1, 2021, at approximately 0100, s/he found MR1 unresponsive in cardiac and respiratory arrest with no alert sounding from the telemetry alarm in the room or at the central monitoring station. EMP7 further revealed as staff began to resuscitate MR1, EMP7 noted at least one of the three telemetry leads was no longer attached to MR1. EMP7 confirmed a check of the central monitoring station immediately after the event revealed the telemetry unit appeared to have alarmed at midnight indicating a telemetry lead was disconnected. EMP7 confirmed staff had not heard a telemetry alarm alert for MR1 prior to MR1 found to be in distress. EMP7 further confirmed it was unknow how long MR1 had been in distress prior to discovering the patient in cardiac and respiratory arrest.
Interview with EMP8 on December 22, 2021, at 1145 revealed s/he became aware of the patient event on Friday, December 17, 2021, at approximately 1500. EMP8 checked the ED telemetry monitors and discovered the alert for a disruption of telemetry signal, such as an unattached lead, was set as a low priority alert. EMP8 further revealed the low priority alert would produce one beep and display 'lead off" and a flat line on the telemetry monitor screen at a patient's bedside and on the monitors at the central monitoring station. EMP8 revealed on Monday, December 20, 2021, s/he contacted [name of vendor] and learned the recently installed telemetry units in the ED were set in the low priority setting, which was the default setting of the manufacturer.
Observation on December 22, 2021, at 1600 revealed the telemetry alarm alert at the central telemetry monitor volume was at 20 percent and barely audible in the ED environment.
Interview with EMP2 on December 22, 2021, at 1600 confirmed the alarm volume on setting the central telemetry monitor was at 20 percent and difficult to hear with the surrounding noise in the ED.
Tag No.: A0283
Based on review of facility policy and staff (EMP) interview, it was determined the facility failed to ensure staff followed approved facility policies by failing to ensure staff reported a patient event and by failing to ensure staff documented an unusual incident, notification of the physician of the event and patient notification of an unusual event in the medical record in one of one applicable medical record reviewed (MR1).
Findings include:
Review on December 22, 2021, of the facility's "Quality Assessment and Performance Improvement (QAPI) Program Calendar Year 20210" revealed "Purpose...The QAPI program helps to drive patient safety, delivery of effective quality care, and excellent patient experiences at UPMC Lock Haven. ...Responsibility and Accountability...Employed physicians, service partners, arranged and contract services play a critical role in ensuring that high quality and safe care is provided to our patients. ...The UPMC Susquehanna Board of Directors holds executive leadership, medical leadership, administrative director/managers, and physician and employee service partners accountable for ongoing quality assessment and performance improvement. ...Patient Safety UPMC Lock Haven maintains and enhances an integrated patient safety program. The Patient Safety Committee is a standing Committee and has responsibilities for oversight of certain Performance Improvement activities as delegated by the UPMC Susquehanna Board of Directors. ... the program works to create a culture which values safety, feels free to disclose errors, and values continuous process improvement. Patient safety events are reported into an electronic reporting system..."
Review on December 22, 2021, of the facility's "Patient Safety Plan," CY2021, revealed "...V. Summaries of Key Elements of Patient Safety Program: A. Internal Reporting System: i. Hospital has in place a system for reporting Reportable Patient Events and Infrastructure Failures 24 hours a day, 7 days a week. ii. The basic elements of the reporting system are: An Initial Incident/Event Report is generated by the individual discovering any Reportable Patient Event. The staff will immediately communicate any significant event that could be a Serious Event, Sentinel Event, and/or Infrastructure Failure to the Nursing Administrative Supervisor. The staff may communicate any potentially Reportable Patient Event to their manager or directly to the Patient Safety Officer. ..."
Review on December 21, 2021, of facility policy "Disclosures of Serious Events/Outcomes of Care" dated December 8, 2021, revealed "I. Policy/Purpose/Scope It is the policy of UPMC to comply with the standards of the [name of accreditation organization] and, as applicable, the Pennsylvania Medical Care Availability and Reduction of Error Act ("Mcare"), 40 P.S. §1303.101, et. seq. ...III. Disclosure of Outcomes of Care...A. [Name of accreditation organization] Standards...3. Reporters and other staff shall notify the attending physician and/or other physicians involved in a patient's care about any Reportable Patient Event that has or could affect the patient's clinical care and shall document the Patient Event in the patient's medical chart... B. General Recommendations for Physician Communications of Outcomes of Care... 3. Notification of significant events or information should be given to the patient as soon as practicable. ... C. Recommendations for Communicating Serious Events and Unfavorable Outcomes...3. The timing, content and persons present at any discussion of an event or condition should be clearly and carefully documented. ..."
Review on December 21, 2021, of facility policy "Initial Incident/Event Reporting (IIER)," dated December 10, 2020, revealed "...IV. Definitions ...I. Reportable Patient Event: Any Incident, Medication Event, Sentinel Event, Serious Event or Infrastructure Failure. ...L. Patient Safety/Peer Review Committee ("Committee"): A committee or committees consisting of health care providers and hospital administrators and staff who evaluate the safety, quality and efficiency of services ordered or performed by a hospital or other health care provider and/or the compliance of a hospital or other health care facility with applicable standards, laws, rules and regulations. ... N. Reporters: Staff members, physicians, employees, volunteers, students or other persons who gain knowledge of a Reportable Patient Event, Reportable Staff Event or Other Reportable Event. ... P. Serious Event: An event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient. The term does not include an incident. ...V. Procedure A. Reportable Patient Events 1. Reporting. Unless he or she knows a report of the event has already been made, a Reporter with knowledge of a Reportable Patient Event shall report the event immediately or as soon as reasonably practical, but no later than 24 hours after occurrence or discovery. ...3. Immediate Communication of Significant Patient Events. When any Reporter gains knowledge of any incident or event that he or she believes has, or if repeated, could compromise patient safety or cause significant patient injury, in addition to completing the IIER, the Reporter shall immediately communicate the event or incident to a member of the Committee. ...4. Physician Notification. The attending physician and/or other physician(s) involved in the care of the patient should be notified of any Reportable Patient Event that has or could affect clinical care. The patient's medical record and IIER should indicate notification of the physician(s).... 5. Documentation in Patient Record. The relevant clinical facts surrounding the Patient Event (and the notification of the event to the attending or other physician(s)) should be recorded in the patient's medical record. ..."
Review of MR1 on December 21, 2021, revealed when staff entered MR1's room on December 1, 2021, at approximately 0100, they found the patient unresponsive in cardiac and respiratory arrest. There was no documentation in MR1 of the disconnected telemetry lead, notification to the physician and notification of the family regarding the event.
Interview with EMP7 on December 21, 2021, at 1300 revealed from 1900 on November 30, 2021, until 0100 on December 1, 2021, MR1 was on telemetry. When s/he entered MR1's room on December 1, 2021, at approximately 0100, s/he found MR1 unresponsive in cardiac and respiratory arrest. EMP7 further revealed as staff began to resuscitate MR1, EMP7 noted at least one of the three telemetry leads was no longer attached to MR1. EMP7 confirmed a check of the central monitoring station immediately after the event revealed the telemetry unit appeared to have alarmed at midnight indicating a telemetry lead was disconnected. EMP7 further confirmed it was unknown how long MR1 had been in distress prior to discovering the patient in cardiac and respiratory arrest.
Interview with EMP4 on December 21, 2021, at 1115 confirmed the event was not reported in the facility's electronic incident reporting system within 24 hours of the event.
Interview with EMP1 on December 21, 2021, at 1450 confirmed no report was submitted via the facility's electronic event reporting system.
Interview with EMP13 on December 22, 20221, at 1715 confirmed the Patient Safety/Peer Review Committee learned of the event on December 17, 2021.
Telephone interview with EMP13 on December 22, 2021, at 1715 confirmed there was no documentation of the disconnected telemetry lead, notification to the physician or notification of the family regarding the event in MR1.
Tag No.: A0385
Based on the seriousness of the non-compliance and the potential effect on patient outcome, the facility failed to substantially comply with this condition.
The findings were:
482.23 Tag A-0392
The information reviewed during the survey provided evidence the facility failed to ensure staff followed the accepted standards of care for patients in the emergency department.
482.23 Tag A-0398
The information reviewed during the survey provided evidence the facility failed to ensure nursing staff in the emergency department were provided adequate supervision regarding following approved facility policies.
A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP4, and EMP5) regarding the survey team's concerns related to Nursing Services on December 22, 2021, at approximately 1430.
Cross reference
482.23(b) Tag A-0392 Nursing Services: Staffing and Delivery of Care
482.23 (b)(3) Nursing Services: Supervision of Contract Staff
Tag No.: A0392
Based on review of facility policy and staff (EMP) interview, it was determined the facility failed to ensure staff followed the facility ' s accepted standards of care in five of 23 MRs reviewed (MR1, MR2, MR3, MR4 and MR5).
Findings include:
A request was made on December 21, 2021, for facility Emergency Department (ED) policies regarding telemetry monitoring, nursing assessment/reassessment, and physician reassessment.
Interview with EMP4 on December 21, 2021, at approximately 1300, revealed the facility does not have ED policies with guidelines outlining telemetry monitoring, nursing assessment / reassessment, and physician reassessment. EMP4 further revealed the ED's standard of care for telemetry monitoring includes running a rhythm strip every hour for patients on telemetry awaiting transfer. Additionally, EMP4 revealed the standard of care for nursing reassessments is every four hours after a transfer order is written and physician reassessment is once per 12-hour shift for a patient awaiting transfer.
Further review of MR1 on December 21, 2021, revealed MR1 was in the ED awaiting transfer for approximately 38 hours following an order for transfer. MR1 contained one telemetry rhythm strip for November 30, 2021, at 0700.
Interview with EMP4 on December 21, 2021, at 1145 confirmed MR1 did not contain documentation telemetry rhythm strips were printed every hour during his/her ED visit.
Review of MR2 on December 21, 2021, revealed MR2 was in the ED on telemetry monitoring and awaiting transfer for approximately 55 hours following the order for transfer. Documentation in MR2 revealed six telemetry rhythm strips and five nursing reassessments were performed during the 55 hours. Provider documentation of reassessment was not present in MR2 from 1318 on October 5, 2021, until 1809 on October 6, 2021.
Interview with EMP4 on December 21, 2021, at 1200 confirmed telemetry rhythm strips were not printed hourly and nursing reassessments did not occur every four hours during MR2's hold in the ED. EMP4 further confirmed a physician reassessment was not documented for the 1900 to 0700 shift on October 5/6, 2021.
Review of MR3 on December 22, 2021, revealed MR3 was in the ED on telemetry monitoring and awaiting transfer for approximately 96 hours following the order for transfer at 1557 on December 3, 2021. MR3 contained no telemetry strips for the time spent holding for transfer. Nursing reassessments were not documented at 1600 on December 3, 1200 on December 4, 1200 and 2200 on December 5, 0400 and 1130 on December 6 and 0000, 0400 and 1200 on December 7, 2021.
Interview with EMP4 on December 22, 2021, at approximately 0930, confirmed there were no telemetry strips in MR3 during his/her ED hold, and nursing reassessments were not documented every four hours per standard of care.
Review of MR4 on December 22, 2021, revealed MR4 was in the ED on telemetry monitoring and awaiting transfer for approximately 59 hours following the order for transfer at 1427 on November 29, 2021. There were six telemetry strips in MR4 for the duration of the stay. A nursing reassessment was not documented until 0800 on November 30, 2021, approximately 18 hours after the transfer order was written. MR4 did not contain a provider reassessment for the 1900 to 0700 shift of November 29/30, 2021.
Interview with EMP4 on December 22, 2021, at approximately 0945, confirmed telemetry strips were not printed every hour during MR4's ED hold, and nursing reassessments and were not documented every four hours and physician reassessments were not documented every shift per the facility ' s standard of care.
Review of MR5 on December 22, 2021, revealed MR5 was in the ED on telemetry monitoring and awaiting transfer for approximately 66 hours following the order for transfer at 1852 on December 4, 2021. There were no telemetry strips in MR5 for the duration of the stay. Nursing reassessments were not documented for 2000 on December 4, 0400, 1200 and 2000 on December 5, 1200 on December 6, and 0400 on December 7, 2021. MR5 did not contain a provider reassessment for the 0700 to 1900 shift of December 6, 2021.
Interview with EMP4 on December 22, 2021, at approximately 1000, confirmed there were no telemetry strips printed during MR5's ED hold, and nursing reassessments were not documented every four hours and physician reassessments were not documented every shift per the facility ' s standard of care.
Tag No.: A0398
Based on review of facility policy and staff (EMP) interview, it was determined the facility failed to ensure staff reported a patient event per approved facility policy.
Findings include:
Review on December 21, 2021, of facility policy "Initial Incident/Event Reporting (IIER)," dated December 10, 2020, revealed "...IV. Definitions ...I. Reportable Patient Event: Any Incident, Medication Event, Sentinel Event, Serious Event or Infrastructure Failure. ...L. Patient Safety/Peer Review Committee ("Committee"): A committee or committees consisting of health care providers and hospital administrators and staff who evaluate the safety, quality and efficiency of services ordered or performed by a hospital or other health care provider and/or the compliance of a hospital or other health care facility with applicable standards, laws, rules and regulations. ... N. Reporters: Staff members, physicians, employees, volunteers, students or other persons who gain knowledge of a Reportable Patient Event, Reportable Staff Event or Other Reportable Event. ... P. Serious Event: An event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient. The term does not include an incident. ... V. Procedure A. Reportable Patient Events 1. Reporting. Unless he or she knows a report of the event has already been made, a Reporter with knowledge of a Reportable Patient Event shall report the event immediately or as soon as reasonably practical, but no later than 24 hours after occurrence or discovery. ... 3. Immediate Communication of Significant Patient Events. When any Reporter gains knowledge of any incident or event that he or she believes has, or if repeated, could compromise patient safety or cause significant patient injury, in addition to completing the IIER, the Reporter shall immediately communicate the event or incident to a member of the Committee. ..."
Review on December 22, 2021, of the facility's "Patient Safety Plan," CY2021, revealed "...V. Summaries of Key Elements of Patient Safety Program: A. Internal Reporting System: i. Hospital has in place a system for reporting Reportable Patient Events and Infrastructure Failures 24 hours a day, 7 days a week. ii. The basic elements of the reporting system are: An Initial Incident/Event Report is generated by the individual discovering any Reportable Patient Event. The staff will immediately communicate any significant event that could be a Serious Event, Sentinel Event, and/or Infrastructure Failure to the Nursing Administrative Supervisor. The staff may communicate any potentially Reportable Patient Event to their manager or directly to the Patient Safety Officer. ..."
Interview with EMP7 on December 21, 2021, at 1300 revealed from 1900 on November 30, 2021, until 0100 on December 1, 2021, MR1 was on telemetry. When EMP7 entered MR1's room on December 1, 2021, at approximately 0100, s/he found MR1 unresponsive in cardiac and respiratory arrest. EMP7 further revealed as staff began to resuscitate MR1, EMP7 noted at least one of the three telemetry leads was no longer attached to MR1. EMP7 confirmed a check of the central monitoring station immediately after the event revealed the telemetry unit appeared to have alarmed at midnight indicating a telemetry lead was disconnected. EMP7 further confirmed it was unknown how long MR1 had been in distress prior to discovering the patient in cardiac and respiratory arrest.
Interview with EMP4 on December 21, 2021, at 1115 confirmed the event was not reported in the facility's electronic incident reporting system within 24 hours of the event.
Interview with EMP1 on December 21, 2021, at 1450 confirmed no report was submitted via the facility's electronic event reporting system.
Interview with EMP13 on December 22, 20221, at 1715 confirmed the Patient Safety/Peer Review Committee learned of the event on December 17, 2021.
Tag No.: A0465
Based on review of facility policy and medical record (MR) and staff interview (EMP) it was determined the facility failed to maintain a complete medical record by failing to document an unusual incident, notification of the physician of the event and patient notification of an unusual event in the medical record in one of one applicable medical record reviewed (MR1) and failed to ensure the patient condition at time of discharge by transfer was documented in four of six MRs reviewed (MR2, MR3, MR4, and MR5).
Findings include:
Review on December 21, 2021, of facility policy "Disclosures of Serious Events/Outcomes of Care" dated December 8, 2021, revealed "I. Policy/Purpose/Scope It is the policy of UPMC to comply with the standards of the [name of accreditation organization] and, as applicable, the Pennsylvania Medical Care Availability and Reduction of Error Act ("Mcare"), 40 P.S. §1303.101, et. seq. ...III. Disclosure of Outcomes of Care...A. [Name of accreditation organization ] Standards...3. Reporters and other staff shall notify the attending physician and/or other physicians involved in a patient's care about any Reportable Patient Event that has or could affect the patient's clinical care and shall document the Patient Event in the patient's medical chart... B. General Recommendations for Physician Communications of Outcomes of Care... 3. Notification of significant events or information should be given to the patient as soon as practicable. ... C. Recommendations for Communicating Serious Events and Unfavorable Outcomes...3. The timing, content and persons present at any discussion of an event or condition should be clearly and carefully documented. ..."
Review on December 21, 2021, of facility policy "Initial Incident/Event Reporting (IIER)," dated December 10, 2020, revealed "...V. Procedure A. Reportable Patient Events...4. Physician Notification. The attending physician and/or other physician(s) involved in the care of the patient should be notified of any Reportable Patient Event that has or could affect clinical care. The patient's medical record and IIER should indicate notification of the physician(s). ... 5. Documentation in Patient Record. The relevant clinical facts surrounding the Patient Event (and the notification of the event to the attending or other physician(s)) should be recorded in the patient's medical record. ..."
Review of MR1 on December 21, 2021, revealed when staff entered MR1's room on December 1, 2021, at approximately 0100, they found the patient unresponsive in cardiac and respiratory arrest. There was no documentation in MR1 of the disconnected telemetry lead, notification to the physician and notification of the family regarding the event.
Interview with EMP7 on December 21, 2021, at 1300 revealed from 1900 on November 30, 2021, until 0100 on December 1, 2021, MR1 was on telemetry. When s/he entered MR1's room on December 1, 2021, at approximately 0100, s/he found MR1 unresponsive in cardiac and respiratory arrest. EMP7 further revealed as staff began to resuscitate MR1, EMP7 noted at least one of the three telemetry leads was no longer attached to MR1. EMP7 confirmed a check of the central monitoring station immediately after the event revealed the telemetry unit appeared to have alarmed at midnight indicating a telemetry lead was disconnected. EMP7 further confirmed it was unknown how long MR1 had been in distress prior to discovering the patient in cardiac and respiratory arrest.
Telephone interview with EMP13 on December 22, 2021, at 1715 confirmed there was no documentation of the disconnected telemetry lead, notification to the physician or notification of the family regarding the event in MR1.
Review on December 22, 2021, of the "UPMC Lock Haven Medical Staff Rules and Regulations," final approval May 12, 2021, revealed "...Article II Medical Records 2.1 Preparation/Completion of Medical Records The Attending Physician shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current. The record shall include... condition on discharge..."
Review of MR2 on December 21, 2021, revealed MR2 was in the ED on telemetry monitoring and awaiting transfer for approximately 55 hours following the order for transfer. Provider transfer documentation recorded MR2 was in stable condition at the time the transfer order was written at 1538 on October 5, 2021. No condition of MR2 was recorded at the time of transfer at 2200 on October 7, 2021.
Interview with EMP4 on December 21, 2021, at 1200 confirmed no patient condition was recorded at the time of transfer.
Review of MR3 on December 22, 2021, revealed MR3 was in the ED on telemetry monitoring and awaiting transfer for approximately 96 hours following the order for transfer at 1557 on December 3, 2021. Provider transfer documentation recorded MR3 was in stable condition at the time the transfer order was written. No condition of MR3 was recorded at transfer at 1515 on December 7, 2021.
Interview with EMP4 on December 22, 2021, at approximately 0930, confirmed no patient condition was recorded at the time of MR3's transfer.
Review of MR4 on December 22, 2021, revealed MR4 was in the ED on telemetry monitoring and awaiting transfer for approximately 59 hours following the order for transfer at 1427 on November 29, 2021. Provider transfer documentation recorded MR4 was in stable condition at the time the transfer order was written. No condition of MR4 was recorded on transfer at 0235 on December 2, 2021.
Interview with EMP4 on December 22, 2021, at approximately 0945, confirmed no patient condition was recorded at the time of MR4's transfer.
Review of MR5 on December 22, 2021, revealed MR5 was in the ED on telemetry monitoring and awaiting transfer for approximately 66 hours following the order for transfer at 1852 on December 4, 2021. Provider transfer documentation recorded MR3 was in stable condition at the time the transfer order was written. No condition of MR5 was recorded at transfer at 1218 on December 7, 2021.
Interview with EMP4 on December 22, 2021, at approximately 1000, confirmed no patient condition was recorded at the time of MR5's transfer.
Tag No.: A1104
Based on review of facility documents and medical records (MR) and staff interview (EMP) it was determined the facility failed to ensure the patient condition at time of discharge by transfer was documented in four of six MRs reviewed (MR2, MR3, MR4, and MR5).
Findings include:
Review on December 22, 2021, of the "UPMC Lock Haven Medical Staff Rules and Regulations," final approval May 12, 2021, revealed "...Article II Medical Records 2.1 Preparation/Completion of Medical Records The Attending Physician shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current. The record shall include... condition on discharge..."
Review of MR2 on December 21, 2021, revealed MR2 was in the ED on telemetry monitoring and awaiting transfer for approximately 55 hours following the order for transfer. Provider transfer documentation recorded MR2 was in stable condition at the time the transfer order was written at 1538 on October 5, 2021. No condition of MR2 was recorded at the time of transfer at 2200 on October 7, 2021.
Interview with EMP4 on December 21, 2021, at 1200 confirmed no patient condition was recorded at the time of transfer.
Review of MR3 on December 22, 2021, revealed MR3 was in the ED on telemetry monitoring and awaiting transfer for approximately 96 hours following the order for transfer at 1557 on December 3, 2021. Provider transfer documentation recorded MR3 was in stable condition at the time the transfer order was written. No condition of MR3 was recorded at transfer at 1515 on December 7, 2021.
Interview with EMP4 on December 22, 2021, at approximately 0930, confirmed no patient condition was recorded at the time of MR3's transfer.
Review of MR4 on December 22, 2021, revealed MR4 was in the ED on telemetry monitoring and awaiting transfer for approximately 59 hours following the order for transfer at 1427 on November 29, 2021. Provider transfer documentation recorded MR4 was in stable condition at the time the transfer order was written. No condition of MR4 was recorded on transfer at 0235 on December 2, 2021.
Interview with EMP4 on December 22, 2021, at approximately 0945, confirmed no patient condition was recorded at the time of MR4's transfer.
Review of MR5 on December 22, 2021, revealed MR5 was in the ED on telemetry monitoring and awaiting transfer for approximately 66 hours following the order for transfer at 1852 on December 4, 2021. Provider transfer documentation recorded MR3 was in stable condition at the time the transfer order was written. No condition of MR5 was recorded at transfer at 1218 on December 7, 2021.
Interview with EMP4 on December 22, 2021, at approximately 1000, confirmed no patient condition was recorded at the time of MR5's transfer.