The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

CARLISLE REGIONAL MEDICAL CENTER 361 ALEXANDER SPRING ROAD CARLISLE, PA 17015 June 22, 2011
VIOLATION: GOVERNING BODY Tag No: A0043
Based on a review of governing body bylaws, facility documentation and interviews with staff (EMP), it was determined that the governing body failed to provide high quality health care to ensure care was provided in a safe setting.

Findings include:

A review on June 9, 2011, of the Carlisle Regional Medical Center's "Bylaws Governing the Operation of the Board of Trustees" last reviewed March 23, 2010, revealed, "It is the purpose of the Board of Trustees to ensure the quality of health care delivered by Carlisle Regional Medical Center (hereinafter sometimes referred to as "Hospital) and Carlisle Outpatient Surgery Center (hereinafter sometimes referred to as "Surgery Center") is the highest order and the Hospital is responsive to the needs of the community which it serves."

A review on June 9, 2011, of facility documentation revealed that on May 23, 2011, the Emergency Department (ED) admitted five patients to ICU (Intensive Care Unit) and 18 patients to the Medical Surgical unit (MS). All 23 ED patient had admission orders written and were waiting to be taken to a room. The admitted patients that were waiting to be taken to a room were held in the ED from less than one hour to 16 hours after being admitted .

A review on June 9, 2011, of the ED staffing revealed that on May 23, 2011, 11:00 PM to 7:00 AM the ED was minus one RN.

A review on June 21, 2011, of Nursing Supervisor Report of May 23, 2011, evening shift (3:00 PM to 11:00 PM) revealed, "... Nursing staff on MS2 very angry secondary to the increased ratios. They voiced concerns for increased acuity, lots of fresh post-op patients ... 3:00 PM to 11:00 PM shift MS2 had 25 patients. MS2 capped at 28 patients, ratios at 1:7 overnight. MS3 census capped at 32 secondary to staffing. This will give the nurses a 1:8 ratio overnight ... Night shift ... Call off for ICU leaves them with 12 patients (full ICU) and 4 RN's. Call made for staffing, messages left, no takers so far ..."

A review on June 9, 2011, of facility documentation revealed that on May 24, 2011, the facility admitted 21 patients to MS/ICU. Twelve of the ED inpatients were kept from four to 18 hours in the ED after being admitted and waiting to be taken to a room.

A review on June 9, 2011, of the ED staffing revealed that on May 24, 2011, 11:00 AM to 3:00 PM ED was minus one RN.

A review on June 21, 2011, of the Nursing Supervisor Report of May 24, 2011, revealed " ... Several calls made for more staffing for MS2 this AM, messages left, no takers. ER made calls for additional staffing ... "Evening Shift"... Census to start is 100 and I have 11 waiting for beds at this time."

A review on June 9, 2011, of facility documentation revealed that on May 25, 2011, the facility admitted 21 patients to MS/ICU. Three of the admitted ED patients were waiting to be taken to a room and were held in the ED over 10 hours.

A review on June 9, 2011, of the ED staffing revealed that on May 25, 2011, 11:00 AM to 3:00 PM the ED was minus one RN.

A review on June 21, 2011, of the Nursing Supervisor Report of May 25, 2011, revealed "... Staffing minimally adequate."

A review on June 9, 2011, of facility documentation revealed that on May 26, 2011, the facility admitted 18 patients to MS/ICU. One ICU patient was held in the ED for five and one half hours and one for three hours after admission orders were written and before they were taken to the ICU.

A review on June 21, 2011, of the Nursing Supervisor Report of May 26, 2011, revealed "... ER holding patients overnight due to staffing ..."

A review on June 9, 2011, of facility documentation revealed that on May 27, 2011, the facility admitted ten patients to MS/ICU.

A review on June 9, 2011, of ED staffing revealed that on May 27, 2011, 3:00 PM to 7:00 PM the ED was minus one RN and 11:00 PM to 3:00 AM the ED was minus one RN.

A review on June 21, 2011, of the Nursing Supervisor Report May 27, 2011, revealed, "Due to staffing issues (3 RN's on each MS unit) and ICU census (11) the ER will be holding admissions tonight."

A review on June 9, 2011, of facility documentation revealed on May 28, 2011, the facility admitted six patients to MS/ICU. Five of the six inpatients were kept seven to 14 hours in the ED while waiting to be taken to a room. One ICU patient was kept for nine hours after admission before they were taken to the ICU.

A review on June 21, 2011, of the Nursing Supervisor Report of May 28, 2011, revealed, "Ratios high. MS floor with 1:7. Patients holding in ED ... Several hours spent making staffing phone calls ... Absolutely no headway made with regard to staffing. This weekend will be a challenge. Staffing inadequate for days, Sunday, on both MS units despite hours of calls being placed earlier ... "

A review on June 9, 2011, of facility documentation revealed that on May 29, 2011, the facility admitted 16 patients to MS/ICU. From 6:10 PM to 9:15 PM the ED simultaneously kept seven MS patients from two to six hours after admission before they were taken to MS.

A review on June 21, 2011, of the Nursing Supervisor Report May 29, 2011, revealed ICU minimum w/current acuity. ER staffing goes down to 3 RN's at 7:00 PM. All attempts made to cover hole by dayshift staff ... "

A review on June 9, 2011, of facility documentation revealed that on May 30, 2011, the facility admitted six patients to MS/ICU. Two MS/ICU patients were kept three hours in the ED after being admitted and waiting for a bed.

A review on June 9, 2011, of ED staffing revealed May 30, 2011, 11:00 AM to 3:00 PM, the ED was minus one RN and 3:00 PM to 7:00 PM minus 1 RN, 7:00 PM to 11:00 PM the ED was minus two RN's, 11:00 PM to 3:00 AM the ED was minus two RN's,

A review on June 9, 2011, of facility documentation revealed that on May 31, 2011, the facility admitted 13 patients to MS/ICU/PCU (Progressive Care Unit). The ED simultaneously kept six MS/PCU patients from one to six hours in the after being admitted . The PCU patient was kept for over four hours after admission before they were taken to a PCU bed.

A review on June 9, 2011, of ED staffing revealed May 31, 2011, 3:00 AM to 7:00 AM the ED was minus one RN, 7:00 PM to 11:00 PM the ED was minus one RN, 11:00 PM to 3:00 AM the ED was minus one RN.

A review on June 21, 2011, of the Nursing Supervisor Report May 31, 2011, revealed, "Staffing low, ED very busy, multiple psych patients in the ED also (made 10 calls to get a sitter w/no takers) ... Several admissions awaiting transport to nursing units and several more pending admissions."

A review on June 9, 2011, of facility documentation revealed that on June 1, 2011, the facility admitted 20 patients to MS/ICU. The ED simultaneously kept nine MS/ICU patients after being admitted . Eight of the nine inpatients were kept for three to seven hours in the ED. The ICU patient was held for four hours after being admitted and before they were taken to an ICU bed.

A review on June 9, 2011, of the ED staffing revealed June 1, 2011, 3:00 AM to 7:00 AM the ED was minus one RN;

A review on June 21, 2011, of the Nursing Supervisor Report of June 1, 2011, revealed, "Staffing on MS3 supplemented with ICU educator, MS educator, MS Clinical Manager. Shift Admin assisting call bells and rounding ... (currently 30 pts; 3 RN's scheduled ... ) ICU educator then finished shift assistance on MS3 and then moved to ICU in response to Post-OP admission requiring ICU recovery and pending ER admission to ICU. Staffing includes 4-RN's ... Census 11 ... Rehab RN called for dinner relief - explained that coverage not available 7 admission holds in ER (6 MS and 1 ICU) ... Calls out to 9 RN's to fill holes for day shift. Left messages, no return calls received ... "

A review on June 9, 2011, of facility documentation revealed that on June 2, 2011, the facility admitted 11 MS/ICU patients and simultaneously kept five MS patients from three to sixteen hours in the emergency room after being admitted and before they were taken to a bed.

A review on June 9, 2011, of ED staffing revealed June 2, 2011, 3:00 AM to 7:00 AM the ED was minus one RN;

A review on June 21, 2011, of the Nursing Supervisor Report of June 2, 2011, revealed, "... Floor staffing ok till nights when it drops to 3 on each. Unable to get agency staff at the last minute ... MS2 census 27/RN's 3...MS3 census 24/3 RN' s'...ICU census 12/RN's 4 ...
ER busy w/3 hold pts at the beginning of the (night) shift and multiple pending admissions ... by 0600 ER holding 8 admissions and more admissions pending. ICU charge aware of PCU pt holding in ER. There are also 4 surgical pts who will require ICU beds post-op today...Staffing for next shift very tight. Spent 40 minutes making calls to fill holes, Left messages, no takers."

A review on June 9, 2011, of facility documentation revealed that on June 3, 2011, the facility admitted 14 MS/ICU patients. Five MS patients were held from six to 17 hours after admission and before they were taken to a bed.

A review on June 21, 2011, of the Nursing Supervisor Report of June 3, 2011, revealed, "Extremely busy 7-3 shift with many ER admissions holds 9 up to 13 holds at one point mid-morning). Census was high and attempts to augment staffing on the MS units were challenging ... Night Shift ... This now gives MS2 only 2 RN's/19 patients...ARU (Acute Rehabilitation Unit) expressing concern re their staffing as at 0300 they will have 1 RN for 16 pts."

An interview conducted on June 22, 2011, at 2:30 PM with EMP18 confirmed that from May 23, 2011, to June 3, 2011, the facility admitted approximately 195 patients to ED/MS/ICU without sufficient staff to care for the patients.

An interview conducted on June 13, 2011, at 2:45 PM with EMP11 revealed that once an order is written, "Patients should be taken to the floor within 30 minutes." EMP11 further confirmed that none of the above patients was offered to be transferred to another facility.

An interview conducted on June 9, 2011, at 9:00 AM with EMP3 confirmed that a week ago they had to hold 14 to 15 MS patients in the ED and at one time there were only three rooms left in which to treat ED patients. "When we tell administration they say we are out of control and troublemakers." EMP3 stated that nurses have left and they are not replaced. EMP3 stated that there is no leadership because the manager of the ED was sticking up for the nurses and was told to leave. EMP3 stated that the ED doctors are locums (a physician who substitutes temporarily) that do not know how to use the computer system so the nurses have to assist the doctors by entering the orders. EMP3 stated that labs are drawn in the anteroom and when the ED has no beds the patients are asked to go back to the waiting room. These patients can be ICU/CCU/PCU or/and MS patients. EMP3 stated that they are never on divert.

An interview conducted on June 9, 2011, at 9:50 AM with EMP5 confirmed that there are times when cardiac arrest comes into the ED and the ED doctor, two nurses and a tech are coding the patient. That leaves one nurse on the floor. Trauma has three other beds and no one is watching them. EMP5 stated that the cardiac monitors don't work right.

An interview conducted on June 9, 2011, at 10:56 AM with EMP7 revealed that Carlisle Regional Medical Center's ED have an increased number of LWOTS (left without treatment). EMP7 stated that the nurses have no time to document. "The same amount of documentation is given for chest pain as a thumb laceration." "The patients have a delay in treatment because of lack of staffing." EMP7 stated, "The holes in the ED were critical and everyone was assisting."

An interview conducted on June 8, 2011, at 12:00 PM with EMP9 revealed that there were no tech's in the ED to watch the cardiac monitor."

An interview conducted on June 13, 2011, at 2:15 PM with EMP 12 revealed that currently there are two registered nurse part-time openings for the peri-oprative area. EMP13 stated that there are no other RN openings throughout the hospital. The interview also revealed that there was no staff to open the pediatric unit. The pediatric unit has not been open for a year. The interview revealed, "Insufficient staff causing a backup in the ED."

An interview conducted on June 13, 2011, at 10:15 AM with EMP6 revealed "It is very difficult to run the ED on full when seeing 80 to 90 patients in 24 hours period and when pulling until full."

A review on June 13, 2011, of Carlisle Regional Medical Center's Patient Safety Policies and Procedures last reviewed March 2011 revealed, " ... CRMC focuses first and foremost on system/process improvements and will not blame the individual(s) involved in the event or seek retribution against the individual for reporting the event."

A review on June 13, 2011, of facility policy "Event Reporting Policy" revised August 2010 revealed, " ... The Event Report shall not be used to address or document disciplinary or personnel actions nor shall it be placed within a staff members' personnel file.

An interview conducted on June 13, 2011, at 10:30 AM with EMP2 revealed that they were afraid of retaliation for talking to The Department of Health (DOH) regarding staffing (an unsafe situation). EMP2 stated that management is aware of the serious staff shortage throughout the hospital and management told the ED nurses to be more creative.

An interview conducted on June 9, 2011, at 9:00 AM with EMP3 revealed that they were afraid of retaliation. EMP3 stated that when we tell administration of the serious staff shortages they say we are out of control and troublemakers. EMP3 stated that the Director of the ER was fired because he/she was speaking out regarding the staffing issues. EMP3 stated that he/she was trying to help us.

An interview was conducted on June 9, 2011, at 10:15 AM with EMP6. EMP6 stated that they were afraid of retaliation for speaking to me. EMP6 stated that when we tell administration of the serious staff shortages they say we are out of control and troublemakers. EMP6 stated that the Director of the ED was fired because he/she was speaking out regarding the staffing issues.

An interview was conducted on June 9, 2011, at 2:00 PM with EMP14. EMP14 stated that the Director of the ER was fired because he/she was speaking out regarding the staffing issues. EMP14 stated that he/she were trying to help us.

An interview conducted on June 9, 2011, at 12:00 PM with EMP9 revealed, "We all fear for our jobs because corporate will fire at will with no reason."

An interview conducted on June 21, 2011, at 3:00 PM with EMP 18 revealed that all the nurses fear for their job because they were talking to DOH. "This is an unsafe place to work and management is aware."

An interview was conducted on June 17, 2011, at 11:30 AM with EMP16. EMP16 stated "A staff member that does not report a serious event can be fired."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on a review of policy and procedures, facility documentation and interview with staff (EMP), it was determined the facility failed to ensure that the established policy and procedure for administration of medications was followed.

Findings include:

A review on June 22, 2011 of facility policy "SafeScan Medication Bar Coding System" last reviewed October 2010 revealed, " ... Time Alerts: ... Scheduled medications have a lead time of 60 minutes and a lag time of 60 minutes, which allows the nurse flexibility to complete medication administrations per the hospital policy."

A review on June 22, 2011, of pharmacy late administration log revealed from May 22, 2011 to June 8, 2011, the percentage of late medication administration in ICU (Intensive Care Unit) was 7.3%; in MS2 (Medical Surgical) 10.4%; MS3 14.7%; PCU (Progressive Care Unit) 28.3%; RHAB (Rehabilitation) 8.9% and WC (Women's Center) 10.8 percent. The facility's total confirmed late medications administered were 11.3%.

An interview conducted on June 22, 2011, at 2:00 PM with EMP1 confirmed the above percentages of late medication administration were the mediations given outside the one hour window.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on a review of facility policy, facility documents and interview with staff (EMP), it was determined that the facility failed to ensure that the Emergency Department (ED) services were provided to meet the emergency needs of patients in accordance with acceptable standards of practice for two of two serious events reviewed (MR5 and MR6).

Findings include:

A review on June 22, 2011, of the facility's "Patient Bill of Rights & Responsibilities" last reviewed August 2008 revealed " ... Patients at Carlisle Regional Medical Center have the right ... to expect emergency procedures to be implemented without unnecessary delay ... "

A review on June 13, 2011, of MR5 revealed the patient arrived in the ED on June 5, 2011, at 3:17 PM. The patient was evaluated, determined to be a critical patient and was scheduled to go to ICU. MR5 revealed the physician ordered a CT scan to be done before going to ICU. The patient was returning from CT scan to the ED at 9:39 PM became unresponsive, resuscitation was attempted and the patient died .

An interview conducted on June 13, 2011, at 9:45 AM with EMP4 revealed the patient was sent to CT scan without a nurse because they did not have staff to go with the patient. EMP4 stated that there were four nurses in the emergency department and the emergency department was full and the waiting room was full. EMP4 stated the patient stopped breathing while in CT scan, was brought back to the ED and died . EMP4 stated that management was aware of the staffing situation throughout the hospital and ED nurses were told that they must be more creative in their care.

An interview conducted on June 13, 2011, at 9:30 AM with EMP6 revealed that the ED was very busy on June 5, 2011, 7:00 PM to 11:00 PM. EMP6 stated the ED had less than minimum staffing. The ED was minus one registered nurse. There were four RN's in the ED to treat all the patients of various acuity. EMP6 stated that the RN did not accompany the patient to the CT scan. EMP6 stated that management was aware of the serious staffing situation.

A review on June 13, 2011, of facility documentation revealed the Emergency Department was minus one registered nurse on June 5, 2011, from 7:00 PM to 11:00 PM and the ED saw at least 25 patients during the time from of 7:00 PM to 11:00 PM.

A review on June 13, 2011, of MR6 revealed, a Cardiologist note dated June 11, 2011, at 11:14 AM, "I did recommend at this point, due to more frequent episodes of syncope and the patient also notes increasing chest pain, predominately involving the right arm and complaints of lightheadedness and dizziness. I did recommend anticipation of transfer to Harrisburg Hospital, with the intent of proceeding with AVR. (Aortic valve replacement)"

A review of MR6 revealed an ED physician's note dated June 12, 2011, at 12:02 PM, "The patient was admitted to the hospital but remained in the emergency room due to staffing issues ... has critical [DIAGNOSES REDACTED] and was pending open-heart surgery with 2 vessel bypass and valve replacement in another 2 weeks ... Unfortunately, while the patient was waiting to get a bed, ... started having what appeared to be vagal episodes...Developed bradycardia and...Blood pressure dropped ... attempted resuscitation and was declared dead ... "

The "Certificate of Death" revealed, "Time of Death 6/11/2011, 6:37 PM." (More than seven hours after the Cardiologist recommended transfer to Harrisburg Hospital)

A review on June 9, 2011 of MR6 revealed there was no evidence that the patient was offered or ordered to be transferred to Harrisburg Hospital.

An interview conducted on June 13, 2011, with at 1:30 PM with EMP1 confirmed that MR6 contained no documentation that the patient was offered or ordered to be transferred to Harrisburg Hospital.

A review on June 9, 2011, of MR6 revealed the following physician note, "Disposition: Disposition to (admission) Telemetry at 06/11/2011 11:12 PM."

A review of facility documentation revealed that the ED was understaffed on June 11, 2011. "The ED was overwhelmed. Nurse patient ratio was 9:1, 6:1 and 7:1. The triage nurse was taking patients and unable to answer call bells. IV (Intravenous) pumps were unavailable. There were delays in getting beds and delays in patients being evaluated by MD. A code occurred and the patient died ."

An interview conducted on June 9, 2011, at 9:45 AM with EMP2 stated, "The patient was admitted to telemetry, a floor bed, because they did not have available beds/sufficient staff in the ICU. EMP2 stated that management was aware of the staffing situation."

An interview conducted on June 21, 2011, with EMP18 revealed that sometimes the Intensive Care Unit (ICU) is full (a capacity of 12 beds) and there are no beds when there is a code in the emergency room and or floor.

A review on June 15, 2011, of the "Nursing Supervisor Report - June 11, 2011," revealed on June 11, 2011, from the 07:00 AM to 23:00 the ICU had 12 patients.

An interview conducted on June 15, 2011, at 2:30 PM with EMP1 revealed that a telemetry bed is a bed on the Medical Surgical floor and the patient wears a cardiac monitoring device (telemetry box) that was monitored by a monitor technician in the ICU department.
VIOLATION: QUALIFIED EMERGENCY SERVICES PERSONNEL Tag No: A1112
Based on a review of facility documentation and interview with staff (EMP), it was determined the hospital Emergency Department did not have sufficient nurses to safely administer nursing care.

A review on June 21, 2011, of the ED approved RN Schedule for June 27, 2011, through July 23, 2011, revealed that there were 233 RN ED time slot/hole vacancies from June 27, 2011 to July 23, 2011. The ED had insufficient staff to cover all shifts.

An interview conducted on June 21, 2011, at 9:45 AM with EMP6 revealed, "The schedule is put out by the scheduling committee." EMP6 stated, "You can't fill holes with people you don't have." EMP6 confirmed there were 233 RN ED vacancies in the original schedule.
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