HospitalInspections.org

Intakes: PA00072325


This condition is not met as evidenced by:
Based on a review of facility documents, medical records (MR) and employee interviews (EMP), it was determined that the facility failed to maintain a safe environment for patients as evidence by: psychiatric patients who eloped from the hospital (A0144), and failing to follow the restraint policy for restraint orders (A0167). This failure resulted in an Immediate Jeopardy, posing a serious risk of harm to the patients.

Cross reference:
482.13(c)(2) Patient Rights: Care in Safe Setting
482.13(e)(4)(ii) Patient Rights: Restraint Or Seclusion

Based on a review of facility documents, medical records (MR) and employee interviews (EMP), it was determined that the facility failed to maintain a safe environment for psychiatric patients who eloped from the hospital for three of twenty two medical records reviewed (MR1, MR21 and MR22).


Findings include:


A review on May 15, 2024, at 10:45, of the facility's policy, "Assessment and Reassessment of Patients" (Last Revised: 3/2023): "Policy: 1. A registered nurse completes the initial assessment or triage. The scope of the nursing assessment is driven by the chief complaint of the patient and is completed at bedside. Anu incidental findings are assessed as they arise. Triage is documented in Notes under ER Nursing Triage ...5. Reassessment of patients occurs when there is a change in patient condition, a change in diagnosis, following any treatment measures and in accordance with policy regarding the taking of vital signs ... All patient reassessments, treatments, medications, and/or procedures are documented in Notes under ER Nursing Note ...".



A review on May 15, 2024, at 11:25, of the facility's policy, "Securing the Safety and Care of Behavioral Health Patients in the Emergency Department" (Issued: 10/2001; Last Revised: 02/2023): "Policy: Penn Highlands Connellsville takes extra measures when caring for behavioral health patients in the Emergency Department to provide for a safer environment for the patients, staff and visitors. Procedure: 4. Patients are medically cleared by the Emergency Department physician. Once medically cleared, mental health is notified for evaluation. Documentation of blood alcohol below the current legal limit is required prior to mental health evaluation when patient has presented with alcohol intoxication ...6. If behavioral health patient is here for a 302 commitment, all attempts including physical restraint must be utilized to prevent patient elopement ...".



On May 15, 2024, a review of MR1 revealed that on May 10, 2024, at 23:07, the patient presented to the hospital via ambulance accompanied by police. According to the medical record the patient stated that they wanted to not be alive. Additionally, the patient injected eight insulin pens and called 911 because the patient changed their mind and wanted to go to the hospital. Upon arrival to the hospital, police were completing a involuntary commitment (302) paperwork and MR1 told the nurse they wanted to be a 302 because they wanted to not be alive. At 01:00, MR1 eloped from the emergency department and the police were called. Additionally, three staff members followed the patient out the door. Further documentation revealed that on May 11, 2024, at 01:04, the patient was found about a block away from the facility. The patient was escorted back to the facility at 01:11. At 01:15 the 302 was granted and at 01:18 Thorazine was given. At 02:45 the patient was found unresponsive, code blue called. At 03:00 the patient was intubated and at 03:15 pronounced dead.


On May 23, 2024, a review of MR21 revealed that on May 15, 2024, MR21 was admitted through the emergency department as Suicidal with Anxiety, Depression and with a plan to overdose. The patient requested help with medication and was admitted to the behavioral health unit (BHU) as a voluntary psyciatric admission (201). On the BHU, MR21 was ordered every 15 minute observation. Further review of MR21 revealed that on May 19, 2024, at 14:35, MR21 eloped from the BHU by following a staff member out of the door. However, the Patient Observation Form continued to be completed by staff which indicated that the patient was in their room at 14:45 and 15:00. Additionally, the faciltiy searched but was unable to locate the psychiatric patient to date.



On May 23, 2024, a review of MR22 revealed that on may May 22, 2024, MR22 arrived at 08:52, in the emergency department accompanied by police threatening too kill herself at home. The 302 was already granted and documentation revealed a negative elopement risk. The patient talked about microphones in their stomach and being Bipolar with suicidal thoughts. At 10:10, MR22 ran to the door, pushed the door open and exited the building. 911 was called and at 10:30, MR22 was returned to the hospital. At 11:17, MR22 was admitted to the BHU.


During an interview on May 23, 2024, at approximately 12:15, EMP2 confirmed the above for MR1, MR21 and MR22.

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the facility failed to follow the restraint policy for restraint orders in one of two medical records reviewed (MR1).

Findings include:

On May 15, 2024, a review of the restraint policy "Non Behavioral, Behavioral and Seclusion Policy" (Last Revised: 9/2023), revealed, "Chemical Restraint: A medication used to restrict the patient's freedom of movement or used for the specific and exclusive purpose of controlling an acute or episodic behavior by the patient. The drug is not standard treatment for the patient's medical or psychiatric condition. A physician order is required. Guidelines: 7. In the event a chemical restraint is ordered to be give aster [sic] the initial dose, the patient must be seen face-to-face by a physician at least once every 12 hours while chemical restraint is being utilized. If the medication is incorporated into the plan of care, it ceases to be considered a chemical restraint. Documentation in the medical record should indicate this incorporation. ...Restraints may only be used when less restrictive interventions have been determined ineffective to protect the patient, staff member or others from harm. The type of technique of restraint used must be the least restrictive intervention that will he effective to protect the patient, staff member or others forrn harm...A written physician order is obtained including: a) Reason for restraint, b) Clinical justification for use of device...".


On May 15, 2024, a review of the medication administration list for MR1 revealed an order on 05/11/2024 at 01:18 for chlorpromazine (Thorazine) injection (50 milligrams per 2 milliliters) for 12.5 milligrams IM (intramuscularly) times one. It was noted on the medication administration list that MR1 received 50 milligrams of Thorazine at 01:18.


On May 15, 2024, at 12:38, EMP6 confirmed the above.

On May 15, 2024, a review of MR1 revealed that MR1 was ordered soft restraints, as a verbal order, on May 11, 2024 at 02:00. Soft wrist restraints were applied. There is no evidence of the required physician signature in the chart.

On May 15, 2024, at 13:55, EMP1 confirmed the above.

This condition is not met as evidenced by:

Based on a review of facility documents, medical records (MR) and employee interviews (EMP), it was determined that the facility failed to provide supervised nursing services by a registered nurse as evidence by: failure to ensure that all licensed nurses adhered to the policies and procedures of the hospital (A0398), and failure to provide the ordered dosage of medication (A0405). This failure resulted in an Immediate Jeopardy, posing a serious risk of harm to the patients.


Cross reference:

482.23(b)(6) Supervision of Contracted Staff

482.23 (c)(1), (c)(1)(i), (c)(2) Administration of Drugs

Based on review of facility polices and medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that all licensed nurses adhered to the policies and procedures of the hospital for one of 22 medical records reviewed (MR21).



Findings include:

On May 23, 2024, review of "Code Green Policy" (Issue Date: 10/2000; Last Revised: 6/2022) revealed, "Policy: Penn Highlands Connellsville will have an efficient and effective method to handle elopements involving patients who are attempting to leave the hospital and are in danger to themselves and others. Procedure: Bullet 1: Any employee that observes a patient fleeing the hospital should immediately dial "2222" from an in house telephone and instruct the switchboard operator to call a "Code Green ..."Bullet 2: Upon hearing the announcement of "Code Green," all available employees on duty should proceed to that area ... Bullet 4: If a patient attempts to flee and appears to be a threat to himself/herself or others, i.e., intoxicated, under the influence of drugs, etc., staff may be instructed to prevent that patient from leaving for their own protection or the protection of others in the community. Physical restraint may be necessary for their protection and the protection of others ...".


On May 23, 2024, review of hospital policy "Behavioral Health Observation of Patients (Connellsville)" (last revised 1/7/2023) revealed, "PURPOSE: To ensure the safety of patients by providing an adequate level of nursing observation at all times ...Individuals entering the program are assessed for their degree of risk during the admission assessment process Routine observation of patients will be conducted by staff to assure patient safety ...all patients are placed on 15 minute observations. Observation type is determined either by a physicians or nursing order. Nursing may place the patient on closer observation than that ordered by a physician if deemed necessary. ... Staff summarize their observations of behavior or verbalizations of assigned patients and interventions and record these in the medical record ...Description of Observation Levels.· Routine 15-minute checks:1. The patient is placed under staff observation every fifteen (15) minutes. The patient is visibly observed by a staff member every fifteen (15) minutes. The patient's location at the time of the check is documented on the Observation Log. Constant Visual Observation: The patient is to remain visible to a staff member. The patient's location is documented on the observation log every fifteen (15) minutes... ".


On May 23, 2024, a review of MR21's Patient Observation Form dated May 19, 2024, revealed that the patient eloped at 14:35. The Patient Observation Form continued to be completed by staff which indicated that the patient was in their room at 14:45 and 15:00, which was incorrect. Additionally, Code Green was never initiated, as per policy.



During an interview on May 23, 2024, at approximately 10:30 AM, EMP2 confirmed the above.

Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined that the facility failed to provide the ordered dosage of medication for one of 22 medical records reviewed (MR1).

Findings include:


On May 15, 2024, a review of "Medication Administration, Scanning, and Documentation" (Last Revised: 04/26/2023) was completed and revealed the following: "Policy: Medications are administered per the order of licensed practitioners with clinical privileges granted in accordance with the Medical Staff Bylaws or Rules and Regulations. Licensed staff may administer medications in accordance with hospital policy, procedure, applicable state laws and practice acts, and governmental rules and regulations ... Bullet 8: Computerized Provider Order Entry (CPOE) sets a standard for all medication orders to be placed by the ordering provider directly into the EMR. Verbal/telephone orders can be accepted only by a registered/graduate nurse (RN/GN) and the read back and verify process must be completed between the RN/GN and provider and documented in the order entry ... Documenting of Medication Administration- Each dose of medication administered is documented on the individual patient record at the time the medication is administered ...".


On May 15, 2024, a review of the medication administration list for MR1 revealed an order on May 11, 2024, at 01:18 for chlorpromazine (Thorazine) injection (50 milligrams per 2 milliliters) for 12.5 milligrams IM (intramuscularly) times one. It was noted on the medication administration list that MR1 received 50 milligrams of Thorazine at 01:18, not 12.5 mg as ordered.


On May 15, 2024, at 12:38, during an interview EMP6 confirmed the above.