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 May 21, 2012
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on review of facility documents, medical records (MR) and staff interviews (EMP) it was determined that Carlisle Regional Medical Center failed to follow its process for prompt resolution of patient grievances for nine of nine medical records with grievances reviewed (MR1, MR17, MR18, MR19, MR21, MR22, MR23, MR24, and MR25).

Findings include:

A review of the facility's Grievance /Complaint Policy, reviewed 9/11 revealed, "... A 'patient grievance' is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient representative, regarding the patient's care...Types of complaint/ grievances: ... patient complaints that become grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding their patient care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more Conditions of Participations. ... ALL verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirement, are to be considered a grievance for the purpose of these requirements. ... A. Processing of verbal complaints: ... 2. The customer/patient feedback report form should be completed immediately stating facts of the complaint and the resolution provides ... B. Complaints not resolved on the spot by staff are 'grievances'... 2.Grievances require written notices (response) to the patient within 7 days ... If the grievance is not resolved within seven (7) days and if investigation is not complete or if corrective action is still being evaluated, the hospital's response should address that the hospital is still working to resolve the complaint and that the hospital will follow-up with another written response within fourteen (14) days. Every effort will be made to resolve all grievances as soon as possible. The hospitals written notice (letter) to the patient will be prepared and sent by the department director for which the complaint involves ... ."

A review on May 7, 2012 of the facility complaint documentation related to MR1 revealed a "Patient Customer Feedback Form was completed on April 10. 2012, by phone and E-mail. The feedback form revealed that the complainant had spoken with the RN Supervisor on April 4 and April 5 2012.

A telephone interview with EMP6 revealed they were the RN Supervisor on duty the night of April 4, 2012. EMP6 stated that a call was received from the complainant with concerns that the patient had not been triaged and was waiting longer than an hour to be seen. EMP6 contacted the Emergency Department and the concern was discussed with the RN Charge Nurse but the patient had already left the Department. The staff filled out an events report that night. Further interview revealed the complainant called back on April 5, 2012. EMP6 stated an attempt was made to answer the the complainant's concern and the matter was referred to the Director of the Emergency Department.

An interview was conducted with EMP7 on May 7, 2012. EMP7 stated that they were not aware of the complaint until April 10, 2012. Further interview revealed an e-mail may have been received and was lost. The e-mail was not able to be located.
A review of the facility Grievance/Complaint Log revealed there were nine Emergency Department complaints for the month of April 2012. A review of the "Patient customer feedback forms" revealed: Every complaint had a response letter sent out eight days later.
A review of the response letters revealed, "Your concern was received on ... and the investigation has begun. The investigation/resolution of your concern is going to take longer than 7 days and every effort is being made to resolve your concerns as soon as possible. You should be receiving a written response by ... ." Further review revealed that five of the nine complaints had not received the final response letter and were past the date indicated on the initial response letters.

An interview was conducted with EMP8 on May 8, 2012, at 9:00 AM. EMP8 revealed the complaints were not resolved per the facility's policy. Further interview confirmed the initial response letter were sent on the eighth day not the seventh as per policy and that the final response letters were not sent timely.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on review of facility documents, and staff interviews (EMP) it was determined that Carlisle Regional Medical Center failed to have an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes.

Findings include:

A review of the facility QAPI data revealed the facility was monitoring the door to triage time.
An interview was conducted with EMP3 on May 3, 2012. EMP3 revealed the time frame is calculated from when the patient presents until the "Triage completed" is populated in the electronic record. However, the electronic medical record system used by the facility documents "Triage complete" once the nurse has entered the patient's mode of arrival, their Chief Complaint and acuity level. A complete assessment including vital signs is not required for the system to populate the "Triage complete."
EMP3 stated that "the QAPI information would not be considered accurate now that we have determined that only three pieces of information need to be entered for the Triage field to populate as completed. We had not been aware of that feature of the system."
An interview was conducted with EMP4 on May 7, 2012 at 9:45 AM. EMP4 revealed the electronic medical record system used by the facility documents "Triage complete" once the patient's mode of arrival, Chief Complaint and acuity level is entered in the system. When those three fields are filled in, the "Triage complete" populates by itself. EMP4 confirmed that a Nurse may not have a completed the Triage per the facility policy but the medical record will indicate "Triage complete."
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical records (MR), and staff interviews (EMP), it was determined that Carlisle Regional Medical Center failed to follow their adopted policy related to the Triage of patients.

Findings include:

A review on May 3, 2012, of facility policy Assessment of the Emergency Department Patient, reviewed September 2011, revealed, " Policy: All patients presenting to the Emergency Department will be triaged and categorized following the Emergency Severity Index 5 level Triage system ... All patients admitted to the Emergency Department will have the following documentation: Chief complaint ... Assessment of psychological status, Initial vital signs ... ."

A review on May 3, 2012, of facility policy Triage of Emergency Department Patients, reviewed September 2011," revealed," Policy: All patients presenting to the Emergency Department for treatment will be assessed by a Registered Nurse. Procedure: The Registered Nurse will evaluate and categorize each patient upon arrival the Emergency Department using the Emergency Severity Index 5 level triage system. Initial evaluation shall include: Patient's name and age, medication and allergies, medical history, subjective - Chief Complaint, objective - nursing observations ... ."

A review of facility documents related to the Triage process revealed a piece of paper that states "Please Complete (please print) across the top in bold, capitalized letters. It has a designated space for patients to write in the following information: Name; Phone number; Date of Birth; Social Security number; Sex: Male or Female; Family Physician; complaint/Reason for Visit."

A review of medical record (MR1) revealed the patient was a [AGE] year old male with the presenting Chief Complaint of " burning in right leg." A review of the Nursing documentation revealed, " Presentation: 4/04/12 6:55 PM presenting complaint: Patient stated: burning in right leg. ... 6:55 PM Method of arrival: walk-in ... 6:55 PM Acuity: ESI 3 ... ED Course: 6:53 PM Patient arrived in ED ... 6:55 PM Triage completed ... 8:14 PM ED Rounding: pt called, not in waiting room. 8:31 PM ED rounding: pt called, not in waiting room. "A review of the physician documentation revealed,"... Disposition Summary: 4/05/12 at 1:02 AM Patient left the facility after triage, from waiting room. Patient stated they are leaving due to wait time." The record lacked documented evidence that vital signs had been taken, or allergies and medications listed as per their policy.

An interview was conducted with EMP3 on May 3, 2012, at 9:00 AM. EMP3 revealed the Emergency Department uses "quick" triage" whenever many patients present at the same time. The patients are seen in the waiting room by an RN who talks to the patient about their Chief Complaint. This process allows for all patients to be seen quickly so that a critically ill patient will be seen first. Our policy does not addresses "quick" triage, and the medical record does not show evidence that the nurse documented the patient's medication and allergies, medical history, Subjective - Chief Complaint, or objective- nursing observations.
An interview was conducted with EMP4 on May 7, 2012 at 9:45 AM. EMP4 revealed the patient did not have a Triage assessment on the medical record (MR1). The staff may have talked with the patient on arrival, but that does not constitute a complete assessment. The electronic medical record system we use documents "Triage complete" once the patient's mode of arrival, Chief Complaint and acuity level is entered in the system. Once those three fields are completed in on the electronic record the "Triage completed" self populates.

An interview was conducted with EMP9 on May 10, 2012, at 11:00 AM. EMP9 stated, "When a patient presents Registration gives them a generic paper to fill out, it asks for their name, date of birth and asks what is wrong with them. Then they are called into Triage, we enter them into MedHost, our computer system. We assign them an ESI, and they are taken to an empty room or returned to the waiting area. We do use a "quick triage" sometimes, that can be done in approximately one and a half minutes. That can be done discreetly in the waiting area. You take their hand, feeling their pulse, to see if it is fast or irregular, ask them their chief complaint. We use quick triage if several patients present at the same time, so it is possible that a patient could sit for hours without being fully triaged. When we do quick triage, we take care of the most acute patient first and then go back to the next most unstable, or if they are equally acute, we take whoever was here first. We do rounds on the patients in the waiting area every half an hour, give them an eyeball and see if they are still waiting. ... ."

A review of facility documents revealed that on May 12 - May 13, 2012, nineteen patients left without treatment. Seven of the patients who left did not have evidence of a complete Triage as per the facility policy, documented in their medical records.
MR33 was a [AGE] year old female with Chief complaint of back pain. Presentation: 05/12/12 at 8:20 PM. Method of Arrival: wheelchair. Acuity: ESI 3. ED Course: 8:21 PM Triage completed. 9:44 PM, ED rounding: Patient seen being pushed out of the ED in a wheelchair by family. The record lacked documented evidence that vital signs had been taken, or allergies and medications listed as per their policy.

MR34 was a [AGE] year old female with Chief Complaint of pelvic pain. Presentation: 05/12/12 at 10:48 PM. Method of Arrival: this area was left blank. Acuity: this area was left blank. ED Course: Patient arrived in the ED. 05/13/12 at 12:09 AM, patient left the ED." The record lacked documented evidence that vital signs had been taken, or allergies and medications listed as per their policy.

MR35 was a [AGE] year old male with a Chief Complaint of a knee injury. Presentation: Patient states knee pain, Patient ambulated into triage without difficulty, appearing in no distress. Method of Arrival: Walk in. Acuity: ESI 4. ED Course: 05/12/12 at 11:05 PM, triage completed. 05/13/12 at 12:44 AM, patient left the ED." The record lacked documented evidence that vital signs had been taken, or allergies and medications listed as per their policy.

MR36 was a [AGE] year old female with a Chief Complaint of pain in side. Presentation: This area was left blank. Method of Arrival: This area was left blank. Acuity: This area was left blank. ED Course: 05/12/12 10:32 PM, patient arrived in ED. 05/13/12 at 1:57 AM, patient left the ED." The record lacked documented evidence that vital signs had been taken, or allergies and medications listed as per their policy.

MR37 was an [AGE] year old male with a Chief Complaint of vomiting and diarrhea. Presentation: This area was left blank. Method of Arrival: This area was left blank. Acuity: This area was left blank. ED Course: 05/13/12 at 12:30 PM, patient arrived in ED. 12:32 PM, Triage completed. 12:41 PM, patient left before triage decided not to be seen." The record lacked documented evidence that vital signs had been taken, or allergies and medications listed as per their policy.

MR38 was a five month old male with a Chief Complaint of coughing blood. Presentation: 05/13/12 at 8:25 PM, mother states blood on burp rag, child currently sleeping. Method of Arrival: Carried. Acuity: ESI 5. ED Course: 8:25 PM Triage completed. 9:14 PM, ED Rounding, called to complete Triage and patients in waiting room advise parents left with child." The record lacked documented evidence that vital signs had been taken, or allergies and medications listed as per their policy.

MR39 was a [AGE] year old female with a Chief Complaint of all over rash and swollen lips. Presentation: 05/13/12 at 10:31 PM. Patient states lip swelling and hands, no [DIAGNOSES REDACTED] noted, patient also complains of numbness in hands, had Benadryl 50 mg three hours ago. Relates symptoms for the past day. No wheezing noted with auscultation of lung sounds and no tracheal stridor noted. Acuity: ESI 3. ED Course: 10:32 PM, Triage completed. 11;02 PM, ED Rounding: Patient seen walking out doors. 05/14/12 at 2:55 PM, Addendum: Patient called back due to being a left without treatment, stated did see a doctor that night at another facility and is feeling much better. ... ." The record lacked documented evidence that vital signs had been taken, or allergies and medications listed as per their policy.