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.
|SHARON REGIONAL HEALTH SYSTEM||740 EAST STATE STREET SHARON, PA 16146||Sept. 26, 2016|
|VIOLATION: STAFFING AND DELIVERY OF CARE||Tag No: A0392|
|Based on review of facility documentation and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure delivery of patient care was consistent with established facility policies for one of one medical records (MR).
Review, at approximately 11:46 AM on September 21, 2016, of Policy 80, Pain Management, reviewed June 2015, revealed, "Each patient has the right to effective pain management throughout the episode of care. Components of an effective pain management plan include accurate assessment of pain, use of appropriate methodologies for prevention and relief of pain ... I. Assessment of Pain: ... B. All patients are reassessed for pain upon instituting any interventions at a time interval appropriate for the type of intervention. C. The single most reliable indicator of the existence and intensity of pain is the patient's self report. D. Pain assessment includes the patient's description of the type of pain, onset, location, duration, intensity, alleviating factors and aggravating factors. ... F. The assessment of pain is considered the fifth vital sign. ... G. Each patient is reassessed for pain at regular intervals with vital signs according to the department routine throughout the episode of care excluding vitals with titration of vasopressors or emergency situations. ... IV. Evaluation A. The effectiveness of pain assessment, prevention and management is evaluated on an ongoing basis with routine vital signs according to department routine. B. Response to pain interventions is evaluated post-intervention at a time interval determined to be appropriate based on the type of intervention. C. Pain is assessed as the fifth vital sign and documented on the Nursing Record. D. Findings of the evaluation are used to identify opportunities to improve structures, processes and outcomes of pain management practices. ... B. Acute Pain ... 2. Emphasis is placed on the prevention of pain and importance of a factual report of pain, avoiding stoicism or exaggeration. 3. Pain is assessed with vital signs per department routine: assessment occurs more frequently when pain is uncontrolled or interventions are changing. ..."
Review, at approximately 12:05 PM on September 21, 2016, of Policy 83, Patient Rights and Responsibilities, effective January 2016, revealed, "... Care Planning and Delivery - you have the right to: ... Receive kind, respectful, safe, quality care delivered by skilled staff. ... Receive proper assessment and management of pain, including the right to request or reject any or all options to relieve pain. ..."
Review, at approximately 2:00 PM on September 21, 2016, of Orientation Power Point Information, dated September 21, 2016, revealed, "... What is Hourly Rounding? ... Eight Behaviors for Hourly Rounds ... Address 4 P's (pain, potty, position, personal items ... Document the round ... Introduce ... Pain How is your pain? If patient answers they have pain- "Thank you for letting me know," Medicate patient or schedule during upcoming rounds ..."
Review, at approximately 2:22 PM on September 21, 2016, of a spreadsheet titled 2016 Sharon Regional Health System Annual Education Review, revealed, "... Pain Management Each patient has the right to effective pain management. Components of an effective pain management plan include: Accurate assessment of pain Use of appropriate methodologies for prevention and relief of pain Reassessment based on interventions and change in condition ... The single most reliable indicator of pain is the patient's self-report. It is all patient care staff's responsibility to monitor the patient's pain and take appropriate action to ensure the patient's comfort. The patient's expectation and perception is to be reviewed. ... Pain Management is to be addressed at "Hourly Rounding" ..."
1. Review of MR2, revealed that the patient was medicated with Norco at 10:58 PM on July 10, 2016. Further review did not reveal a pain reassessment in conjunction with the administration of that Norco.
2. Review revealed that the patient did not receive any additional pain medication, nor another pain assessment until 12:07 PM on July 11, 2016.
3. At approximately 8:16 AM on September 26, 2016, EMP1 confirmed that he/she was unable to locate additional documentation regarding pain assessments and/or medications for MR2.
|VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES||Tag No: A0749|
|Based on direct observation and employee interviews (EMP), it was determined that the facility failed to ensure that the Emergency Department (ED) was maintained in a manner to sustain sanitary characteristics and minimize health hazards in the waiting room area, patient care rooms and the interior ED hallway.
Review, at approximately 11:35 AM on September 21, 2016, of ED Cleaning Procedure, Chapter 8 Environmental Services - Cleaning Procedures Manual, Sodexo 2011 sdx1109, Page 192-193, revealed, "... This procedure covers the daily cleaning instructions for emergency room s. ... Procedure 1. Prepare germicidal solution as directed. 2. Daily opening is performed using the Shine - 7 Step Cleaning Process described on page 20. Step 1 - Pull trash and linen. Step 2 - Complete the High Dust process. Step 3 - Damp wipe all contact surfaces. Step 4 - Thoroughly clean the restroom. Step 5 - Dust mop properly. Step 6 - Damp mop all appropriate areas. Step 7 - Inspect the work according to the Shine standards. 3. Check with the nurses' station at start of shift, after each break, and again after lunch for any immediate needs. 4. In some hospitals, Environmental Services is responsible for cleaning the room after each patient is discharged . Ask your manager what your responsibilities are. If between case cleaning is required: Empty trash Disinfect stretcher Disinfect ledges Disinfect counter tops Disinfect anything visibly soiled Dry mop floors Damp mop floors Inspection Standards Ceilings, ledges, countertops, furniture, and cabinets are clean and free of dust. Waste receptacles are clean and relined. Wash basins are clean and free of mineral build-up. Floor is free of dust, spills, or body fluids. ..."
1. A tour of the Emergency Department (ED) area was conducted on September 21, 2016, from 10:20 AM to 10:45 AM. EMP7 was present for the tour. One person was observed sitting in the Waiting Room at the time of the observation.
Observation in the ED waiting room at 10:27 AM revealed sugar and debris on the floor near a coffee station, debris and food crumb underneath the central seating area, and debris located adjacent to three trash cans. EMP7, confirmed the findings at the time of the observation.
2. Observation in the ED, Room #18, at 10:30 AM revealed the bed was made and the room appeared ready to receive a patient. The observation further revealed debris on the floor as well as an alcohol swab that had been removed from its wrapping. EMP7 confirmed the findings at the time of the observation.
3. Observation in the ED, Room #16, at 10:33 AM revealed the bed was made and the room appeared ready to receive a patient. The observation further revealed dirt and grass on the floor next to the treatment bed in a puddle of water. EMP7 confirmed the findings at the time of the observation stating, "I'll get Housekeeping."
4. Observation in the ED, Room #14, at 10:34 AM revealed the bed was made and the room appeared ready to receive a patient. The observation further revealed debris on the floor and under the bed. EMP7 confirmed the findings at the time of the observation.
5. Observation in the ED, Room #4, at 10:39 AM revealed the bed was made and the room appeared ready to receive a patient. The observation further revealed a chuck pad hanging from a cupboard, touching the floor. EMP7 removed the item and confirmed the findings at the time of the observation.
6. Observation in the interior ED hallway at 10:42 AM revealed a heavy accumulation of dust located underneath linen hampers. EMP7 confirmed the observation stating, "I sure do [see the accumulation]."