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.

LEHIGH VALLEY HOSPITAL - HAZLETON 700 EAST BROAD STREET HAZLETON, PA 18201 Jan. 3, 2013
VIOLATION: PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES Tag No: A0120
Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to provide a written response for a complaint filed with the facility's patient advocate.

Findings include:

Review on January 3, 2013, of the facility's "Patient Grievance Process," dated reviewed January 12, 2012, revealed "Purpose: To insure that patients are aware of their rights whenever admitted to Hazleton General Hospital, whether for an inpatient or outpatient stay to insure that their complaints and grievances are addressed in a timely manner. Scope: This policy applies to all employees of GHHA [Greater Hazleton Health Alliance] Facilities. Policy: 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's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS [Centers for Medicare and Medicaid Services] Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by CMS guidelines. ... Procedure: ... #7 Every effort will be made to resolve the complaint or grievance within a thirty day period. If circumstances require that the resolution require more than a thirty-day time frame, the patient and/or party acting on the patient's behalf will be informed that the hospital is still working to resolve the grievance and that the hospital will follow up with a written response pending resolution. #8. The patient and/or the party acting on the patient's behalf will receive a written notice of the hospital's decision that contains the name of the hospital's contact person, the steps taken on behalf of the patient advocate to investigate the grievance, the results of the grievance process, and the date of completion (within regulatory boundaries e.g., peer review).

Review on January 3, 2013 of facility policy "Patient Complaints," dated reviewed July 2012, revealed "Purpose: To insure that patients are aware of their rights whenever admitted to Hazleton General Hospital, whether for an inpatient or outpatient stay, to insure that complaints are addressed in a timely manner. Scope: This policy applies to all GHHA Healthcare Facilities. ... Procedure: ... #5 Every effort will be made to resolve a patient complaint within a thirty-day period. If circumstances require more than a thirty-day time frame, the patient and/or party acting on the patient's behalf will be informed of the delay".

Review on January 3, 2013 of the facility's complaint log for the time period of October 9, 2012, until January 3, 2013, revealed a complaint filed on November 27, 2012, with EMP12 regarding the treatment the complainant's child received while a patient in the Emergency Department of Hazleton General Hospital on November 22, 2012. Further documentation revealed the complaint was to be followed up by the acting patient advocate, EMP6. Continued review of the facility's complaint log revealed no documentation the facility did follow-up on the complaint of November 27, 2012.

Interview on January 3, 2013, at approximately 11:00 AM with EMP6 confirmed there was no follow-up regarding the complaint filed on November 27, 2012.

Interview on January 3, 2013 at approximately 11:15 AM with EMP1 confirmed the facility's Patient Advocate was out on medical leave, and EMP6 was the Acting Patient Advocate.
VIOLATION: WRITTEN MEDICAL ODERS FOR DRUGS Tag No: A0406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility documents, medical records (MR) and interview with staff (EMP), it was determined the facility failed to insure oxygen was administered only upon written and signed orders of a practitioner.

Findings include:

Review on January 3, 2013, of the "Medical Staff Bylaws of Hazleton General Hospital," dated revised and approved April 25, 2012, revealed "... Article II Medical Orders Section 1. General Requirements, (a) Orders must be written clearly, legibly, timed, dated and signed with no unauthorized abbreviations and complete. Orders which are illegible or improperly written will not be carried out until they are rewritten and are understood by the nurse. The use of 'renew', 'repeat', and 'continued' orders alone are not acceptable. (b) All previous orders including standing drug orders, are cancelled when patients go to surgery and must be re-written following surgery. (c) All orders will be completely rewritten when a patient is transferred from one service to another or when medications or treatments is to be resumed after an automatic stop order has been employed. It is not necessary to rewrite orders when a physician is providing on-call coverage for another physician. (d) Only the abbreviations, signs and symbols listed in Appendix A to these rules and regulations shall be used in the medical record. No abbreviations, signs or symbols may be used in recording the patient's final diagnosis or any unusual complications."

Review on January 3, 2013 of MR1 revealed the patient, a five-month-old, presented to the Hazleton General Hospital's Emergency Department on November 22, 2012, at 1:00 PM. Nursing triage documentation revealed MR1's mother provided the history. MR1 had a recent diagnosis of [DIAGNOSES REDACTED].

Interview on January 3, 2013, at approximately 10:30 AM with EMP5 revealed EMP5 instructed the mother to administer "Blow By" oxygen to the patient. This consisted of oxygen tubing being inserted through the bottom of a medicine cup via a puncture hole made at the bottom of the medicine cup with scissors, and the cup then waved back and forth across the patient's face.

Continued review of MR1 revealed no physician order for oxygen, the amount of oxygen in liters to be administered, or the "Blow By" oxygen treatment.

Interview on January 3, 2013, at approximately 10:30 AM with EMP5 confirmed there was no documentation in MR1 of a physician's order for oxygen or the "Blow By" treatment.

Interview on January 2, 2013 at approximately 11:15 AM with EMP3 confirmed oxygen "Blow By" treatment was a clinical decision made by the physician after assessment of the patient.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure isolation of an emergency room patient with a recent history of Respiratory Syncytial Virus (RSV).

Findings include:

Review on January 3, 2013, of facility document "Initiating Isolation Precautions," dated reviewed September 2012, revealed "Policy: In order to provide the necessary protection for all employees, families and patients, it is the Policy of Hazleton General Hospital to initiate isolation precautions when there is reason to believe that a patient possibly has an infectious or communicable disease. Procedure: 1. Should there be a reason to believe that a patient possibly has an infectious or communicable disease, the patient should be placed in isolation. 2. A physician's order is not a necessity: however, the fact that the patient was put into isolation should be documented either by a physician order or on the nurse's notes/care plan for the patient. 3. Should the physician not agree to isolation, the Nursing Supervisor/Nurse Manager or the Infection Control Practitioner has the authority to continue isolation. 4. Isolation precautions shall remain in effect until the patient is no longer contagious.

Review on January 3, 2013 of MR1 revealed the patient, a five-month-old, presented to the Hazleton General Hospital's Emergency Department (ED) on November 22, 2012, at 1:00 PM. Nursing triage documentation by EMP7 revealed MR1's mother provided the history. MR1 had a recent diagnosis of Respiratory Syncytial Virus (highly contagious virus that can be spread through droplets containing the virus when someone coughs or sneezes). At 1:05 PM, the mother and infant patient were instructed to go to the waiting room area of the ED until an ED room was available. At 2:03 PM, the patient was examined by EMP5. A diagnosis of RSV / positive bronchiolitis was made.

Interview on January 3, 2013, with EMP5, at 10:30 AM, revealed they were unaware of the facility policy addressing isolation.

Interview with EMP10 on January 3, 2013, at approximately 11:40 AM noted the isolation process for an RSV patient would be as follows. A nasal swab should be obtained, and the patient is considered a high priority. The patient is then put in isolation, if available, but is not exposed to the general population of the ED.

Interview with EMP11 on January 3, 2013, at approximately 11:45 AM confirmed that when an RSV patient presents to the ED the patient is to be registered and triaged. The severity of the respiratory condition is then determined. If an isolation room is not available the patient should remain in the hallway outside the triage area until an isolation room is available.