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.

UPMC ALTOONA 620 HOWARD AVENUE ALTOONA, PA 16601 July 20, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on a review of facility documents, and interview with staff (EMP), it was determined that Altoona Regional Health System failed to provide patient care in a safe setting during a construction project.(A- 0144)


Findings include:


A Review of "Altoona Regional Health System, Standard Practice, Subject: Patient Rights and Responsibilities" dated April 20, 2011, revealed " ... Patient Rights and Responsibilities Altoona Regional Health System respects and supports the basic human, civil, constitutional and statutory rights of patients. ... ."

1) An interview was conducted with EMP1 on July 13, 2011, at approximately 1:30 PM, "There are no set policies on how to communicate with staff when construction requires services to be shut down." (A- 0144)


2) A telephone interview was conducted with EMP7 on July 13, 2011, at approximately 8:24 AM. "The supportive services person brought the patient down around 1:30 AM, and I asked the other CT/RTs (Cat Scan/Radiology Technicians) to help me move the patient on to the table. The patient was not on a monitor, no nurse came with them, the patient had labored breathing and was on a face mask at 15 Liters. I turned the wall oxygen on and the ball went up and I felt something flowing. I did not see any indication that we were not supposed to use the wall outlets. I did not notice an oxygen tank in the room that night, no one told me to use a tank. Even if I would have seen a tank, I would have hooked the patient up to the wall outlet. The patient was alert and talking, The patient told me that a nurse pushed them and they fell . Patients tell us all kinds of things, so I wasn't sure if patient was oriented, I just chuckled. Patient then said no, really, I provoked the nurse. I strapped the patient in and started the scan. The patient's breathing was labored and they could not keep their head still. ... . I was talking to the patient through the intercom, telling the patient to take slower breaths, the patient said okay, but didn't do it. Another tech was in the room with me, watching the patient and I was watching the cameras. The tech said that the patient's arm just fell . We ran in and pulled patient out, I tried to talk to patient, patient just took a couple of big gasps, ... and we called a code. ... then the phone rang, it was the patient's nurse, the nurse informed us that patient was a DNR (Do Not Resuscitate), so we did not take any further action. I was talking with the doctor about what happened to the patient. At some point a maintenance person came in from the hallway and asked the Emergency Department (ED) RN if the patient in the Code was hooked up to the wall outlet, because they were flushing the lines. It was days later that the ED RN came over and asked me if I knew about the lines, I was never told. ... We are distraught, this should not have happened. They send us emails about all kinds of things, like the toilet in the locker room, they should have sent us one about this. We checked our emails, we never got any about this. They usually communicate things to us via Email, but we come on at 11:00 PM and most days it is too busy to check our Email, like the other day, I came in and had to go straight to the OR, when I was done, I had to relieve CT ." (A- 0144)


3) An interview was conducted with EMP10, on July 17, 2011, at approximately 09:25 AM, "I was working in the Emergency Department when I heard the Code Blue called. We had someone over in CT earlier. We responded to the code at approximately 1:30 AM, Dr. ... and myself. When we arrived Dr. ... went to assess the patient. I was going to get the crash cart. ... While Dr. ... was assessing the patient the phone rang and I answered it, it was the nurse from the Progressive Care Unit. The nurse asked if it was patient so and so, and that the patient was a Do Not Resuscitate (DNR). I looked at the chart and confirmed the written order for DNR. I took the order out of the chart and showed Dr. ... We did not pursue any other interventions. We were discussing what just happened. I saw EMP3 peaking through the door, pacing back and forth. They motioned for me to come out into the hallway. They asked if the patient was hooked up to the wall oxygen, and that the oxygen was shut down for construction. I told them that air was coming out of the wall unit. That is when they told me that the lines were filled with nitrogen. I spoke with EMP9 about what EMP3 said. By this time we were prepping the body to go back up to the floor. We were not informed that the gases were down. I asked if the gases were down in the Emergency Department, and learned that the medical air was down. We were never informed of the shut down." (A- 0144)



4) An interview was conducted with EMP9, On July 19, 2011, at approximately 09:00 AM, "I knew the patient had fallen, the nursing staff notified me. The resident came and assessed the patient. The resident ordered a CT scan. I knew the patient was going for the scan. I was on the floor when the code was called. The staff nurse told me that the patient sent down was a DNR. This occurred at approximately 1:30 AM. I did not know that the oxygen was shut down in the Imaging department. I knew something was going on when I got to the Imaging department. The CT Tech stated that air was coming out of the oxygen regulator. This was confirmed by EMP10. EMP10 stated that there was air coming out of the regulator and that the ball in the regulator was floating. EMP10 approached me and said that they needed to talk to me in the hall. I went into the hall and EMP10 and EMP3 stated that the oxygen was shut down. EMP3 stated that the oxygen lines were being purged with nitrogen. I had the staff fill out ... report. Respiratory was the only department that had been notified. I did not get an e-mail notification. EMP4 was not aware of the medical gas shut down. I notified EMP1 and had the staff write ... . We called the patient's brother. We had prepared the patient and took the body back up to Tower 12. ... ." (A- 0144)


Cross Reference:
482.21 QAPI
482.21 Physical Environment
VIOLATION: QAPI Tag No: A0263
Based on a review of facility documents and interview with staff (EMP), it was determined that Altoona Regional Health System failed to maintain an ongoing, hospital wide quality assessment and performance improvement program (A-0265) during a construction project by failing to minimize the risk and by failing to ensure that clear expectations to ensure patient safety were established. (A-0314)

Findings include:

A review of Altoona Regional Health System Plan for Continuous Performance Improvement revealed, "Objectives of the Altoona Regional Health System Continuous Performance Improvement Process: Altoona Regional Health System has adopted Continuous Performance Improvement as a key element in its efforts to achieve high quality and efficiency. The objectives of this process are: ... To provide an environment that encourages collaboration among staff and professional disciplines to enhance safety and quality throughout the Altoona Regional Health System. ... To promote care coordination to achieve optimal outcomes. To optimize patient safety and minimize risks and unanticipated adverse events by improving processed of providing patient care. I. Authority for the Process: The Altoona Regional Health System's Board of Directors is ultimately responsible for assuring that a culture of safety and quality is created and maintained throughout the Health Care System and that the care and services provided are of the highest quality, are cost effective, and are responsive to the needs of the region. ... the Health System's Senior Leadership ensures that adequate space, equipment, information systems, and trained personnel are in place to develop, implement, maintain, and improve the process. ... Process/Information Flow: ... 7. Each Departmental and Committee Chair or Director will ensure that mechanisms are in place to : ... Identify important aspects of care and monitor these against criteria reflecting current standards of acceptable procedures, practices, and performance. ... Patient Safety: recognizing the trust that patients and their families place in us, the Altoona Regional Health System strives to optimize patient safety and minimize the risk of medical/health care errors by improving the processes we use to provide care. ...

A review of the "Narrative Description For The T-1 ED expansion and Imaging Alterations Altoona Regional Health System - Altoona Hospital Campus, Altoona, PA. June 8, 2010. General description: As part of its Consolidation of Inpatient Care to Altoona Hospital Campus (ACH), the Altoona Regional Health System is expanding its Emergency Department. For this to occur, under separate projects; (1) the Nuclear Medicine Program is moving to the first floor of Outpatient Center Building (OP-1) directly connected to the Tower Building and (2) a Cath Lab currently located on T-1 will be relocated to OP-2 as part of a Cath Lab expansion project. As part of this project, in order to accommodate the expanded Emergency Department, the Radiology Department will be partially relocated/renovated on the first floor of the Tower Building (T-1). Finally as part of this project, on OP-1 space that is soon to be vacated will be renovated for E. D. Male and Female Lockers and Office space for radiology Administrative Staff. This will be a multiple phase project; it is an ICRA Class III with High patient risk group and a Type C Construction project activity. New Roof Top Air Handlers will be added and placed on a roof above the two story section of the Tower - one will serve the E.D. and the other the Radiology Department. Sections referenced below are from the 2006 Guidelines for Design and Construction of Health Care Facilities. ..."
It is noted that the Narative Description failed to contain direction for the medical gas relocation. (A-0265)

1) An interview was conducted with EMP1, on July 12, 2011, at approximately 09:15, "On June 29th the medical gases were to be shut down from 7:00 PM until 11:00 PM. The contractors ran into problems and the project took longer than expected. There was no communication to the staff that the contractors purge the oxygen lines with nitrogen." (A-0265)


2) An interview was conducted with EMP5, on July 12, 2011, at approximately 11:05 AM, "Approximately a week in advance I told second shift that next week they are going to do the oxygen and vacuum lines and the system will be shut down. I told the staff verbally and I can not remember who was there when I told them. It was second shift. To be honest I completely forgot about it. ... The third shift did not know of the shut down." (A-0314)



3) An interview was conducted with EMP1 on July 13, 2011, at approximately 1:30 PM, "There are no set policies on how to communicate with staff when construction requires services to be shut down." (A-0314)




Cross Reference:
482.13 Patient Rights
482.41 Physical Plant
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on review of facility documents, and interviews with staff (EMP), it was determined that Altoona Regional Health System failed to ensure that high professional standards were maintained (A-0701) and that written procedures were established for employees to follow to maintain safety and to minimize all health hazards in the hospital during a construction project (A-0703) for the protection of the patients.

Findings include:


A review of Altoona Regional Health System, Standard Practice, dated April 4, 2011 and revised April 4, 2011, revealed, " Subject: Utilities Management, A Utilities Management Plan has been developed in order to provide a safe and comfortable environment for the patients, visitors, and employees of Altoona Regional Health System. The Director of the Engineering has overall responsibility for establishing and maintaining the Utilities Management Program. The Director of Engineering, in conjunction with departmental staff, is responsible for overall maintenance of the facility, major utility systems, and management of contractors who provide a variety of services. The management plan, which is detailed in Altoona Regional Health System's Disaster Manual, includes a description of the Hospital's electrical system, natural gas acquisition, medical gas, HVAC systems, infection control, use of the pathological incinerator, nurse call system, nitrogen system, and the water/sewage system. A separate water plan and communications plan are included in the Disaster Manual. The Environment of Care Department has established and maintains emergency procedures for all utilities, which are outlined in the departmental plans. The electrical system section describes ... . The natural gas section describes ... . The Medical gas system includes medical air, vacuum, oxygen, nitrogen, and nitrous oxide. In the event of a disaster, the Nursing Staff would assess the patients and their requirements and would ensure continuation of necessary gases and air manually and advise the responding fire department personnel of the locations of the medical gas (oxygen) and medical air shut-offs ... The HVAC section ... . The Supply Chain Department is responsible for monitoring the supply of nitrogen and nitrous oxide and reordering, when necessary. ... However, the Engineering Services Department does assist in conduction pressure readings, changing HEPA filters, and ensuring that the exhaust system is operating properly. Communications for the Hospital is handled through the Information Systems Department. ... . The Safety Committee will evaluate on an annual basis the objectives, scope, performance, and effectiveness of the Utilities Management Program. "

A review of Altoona Regional Health System, Standard Practice, Subject: Utility System Shutdowns During A Construction Project, dated April 29, 2011, revealed, " Subject: ... In the course of a construction project, there will be occasions that utility systems (i.e., water, medical gas/vacuum, electrical, steam) will need to be shut down or shut off for periods of time. All outages must be coordinated through the Engineering Director. If possible, at least a two-week notice needs to be provided to the Engineering Director of the outage and should be planned with the least amount of disruption. Specific department needs (i.e., drinking water for the Emergency Department) must also be addressed by the Engineering Director. All valves shall be opened or closed by Hospital personnel only. This pertains to water, steam, and gas outages. ... . "

Review of Altoona Regional Medical Center " Utilities Management - Altoona Hospital Campus ... Medical Gases. The medical gas system includes medical air, vacuum, oxygen, nitrogen, and nitrous oxide. Medical air pumps and the vacuum pumps are monitored continuously. Preventive maintenance is performed as per factory recommendations based on the number of hours on the machine. Some preventive maintenance is performed by in-House maintenance personnel and the remainder by an outside vendor. If the medical air, vacuum, oxygen, nitrogen and/or nitrous oxide supplies are hindered in any way, refer to Nursing Service Standard of Practice for appropriate follow up.

1) An interview was conducted with EMP2 on July 12, 2011, at approximately 10:30 AM, "Med gas upgrades would have been submitted to Harrisburg for approval. We like to pride ourselves on getting projects done timely. We have never gone over the scheduled time to complete a project. We think it was the contractors process. ... The entire facility is not notified of a shut down. The initial notification comes from us (facilities), since we are overseeing the project. Then we send it to the various departments that are affected by the project. We always notify Respiratory when the construction impacts the medical gases. I do not believe in notifying the whole facility if they are not affected by the construction. I have never blocked the outlets in the past. If there was a regulation we would have been on it." (A-0701, A-0703)

2) An interview was conducted with EMP3, on July 12, 2011, at 10:00 AM, "With the phasing of the Emergency Department construction the old medical gas lines had to be moved. The medical gas system was to be shut down on June 29th at 7:00 PM to 11:00 PM. When we discussed the shut down with the contractor they requested three hours to complete the job. We gave them an additional hour. The whole first floor was affected. I know a lot of e-mail notifications regarding the shut down were sent to Respiratory Department, the Emergency Department and Imaging. No one informed the Imaging department that the work was going beyond the scheduled time frame. It took a total of 6 1/2 hours to complete, the contractors finished around 2:00 AM. ... No staff ever asked if the project was completed. ... I went running down to CT to see what was going on. This is when I learned that the patient was connected to the wall oxygen. The rooms all had portable O2 (oxygen) cylinders, staff was aware that we were working there. The support person would have seen the contractors because they were working outside the CT room in corridor X-126. They would have had to pass the contractors to go to the room." (A-0701, A-0703)


3) An interview was conducted with EMP1 on July 13, 2011, at approximately 1:30 PM, "There are no set policies on how to communicate with staff when construction requires services to be shut down." (A-0701, A-0703)


Cross Reference:
482.13 Patient Rights
482.21 Quality Assessment and Perfromance Improvement Program