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.
| MILTON S HERSHEY MEDICAL CENTER | 500 UNIVERSITY DRIVE HERSHEY, PA 17033 | April 13, 2017 |
| VIOLATION: COMPLIANCE WITH LAWS | Tag No: A0020 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, medical records (MR), Department of Health's (Department) database, and staff interview (EMP), it was determined the facility failed to conform to all State laws: Milton S Hershey Medical Center was not in compliance with the following State law: The Medical Care Availability and Reduction of Error Act, 40 P.S. 1303.101 et seq. 1303.313 Medical Facility reports and notifications (a) Serious event reports A medical facility shall report the occurrence of a serious event to the department and the authority within 24 hours of the medical facility's confirmation of the occurrence of the serious event. The report to the department and the authority shall be in the form and manner prescribed by the authority in consultation with the department and shall not include the name of any patient or any other identifiable individual information. (b) Incident reports A medical facility shall report the occurrence of an incident to the authority in a form and manner prescribed by the authority and shall not include the name of any patient or any other individual information. (c) Infrastructure failure reports. A medical facility shall report the occurrence of an infrastructure failure to the department within 24 hours of the medical facility's confirmation of the occurrence or discovery of the infrastructure failure. The report to the department shall be in the form and manner prescribed by the department. This is not met as evidenced by: Based on review of facility documents, medical records (MR), Department of Health's (Department) database, and staff interview (EMP), it was determined the facility failed to report a serious event to the Department and the Patient Safety Authority within 24 hours of the occurrence. Findings include: A review on April 13, 2017, of the facility's "Performance Improvement Plan," effective June 2016, revealed "...External reporting...Serious events and infrastructure failures will be reported to the DOH within 24 hours of confirmation of occurrence via the Pennsylvania Patient Safety Reporting System. Serious Events will be reported to the Patient Safety Authority within 24 hours of confirmation of occurrence via the Pennsylvania Patient Safety Reporting System. ..." A review on April 12-13, 2017, of MR1 revealed the patient arrived in the Emergency Department on January 10, 2017, at 2:51 PM, with a temperature of 89.4 degrees F, rectally. A Bair Hugger (blanket warmer device) was applied to the patient. The following patient temperatures were obtained rectally: 90.8 F at 8:16 PM, 92.8 F at 9:14 PM, 97.8 at 10:44 PM, and 98.0 F at 12:14 AM on January 11, 2017. There were no other temperatures documented until 10:22 AM on January 11, 2017. The patient's rectal temperature at that time was 107.6 F. A review of physician inpatient note addendum dated January 13, 2017, revealed "...We came and saw him in ED around 10 AM. There were no vitals and his last temp was around midnight. The nurse during the rounds told us him temp was now 42 C {107.6 F}. We asked about the Bair Hugger and it had been on high all night. ..." The patient was transferred to pediatric intensive care unit (PICU). A review of the discharge summary, revealed, the patient "...arrived to the PICU in shock with ECG changes consisting of QRS widening and ST elevation, worrisome for conduction system impairment in addition to myocardial functional impairment. ...Despite all these measures, QRS degenerated, there are episodes of pulseless [DIAGNOSES REDACTED] superimposed on a baseline of persistent hypotension. ...Hypotension persisted, with chaotic QRS morhphology and unstable hemodynamics despite ongoing resuscitative efforts. He expired at 5:39 PM." A review of the Department's database revealed the facility reported the above incident on March 29, 2017, to the Pennsylvania State Reporting System (PSRS), 77 days after the event. An interview conducted on April 12, 2017, at 11:45 AM with EMP9 confirmed the facility did not report the event until March 29, 2017. EMP9 stated the facility became aware after the Patient Safety Authority sent the facility a letter dated March 3, 2017, regarding the event. EMP9 stated that an employee reported the event anonymously to the Patient Safety Authority. EMP9 confirmed that no one from the facility had entered the event into the facilty's internal reporting system. EMP9 stated that he would have expected multiple reports regarding this event. EMP9 further stated that "Hands down, no questions, it should have been reported right away." |
||
| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| Based on review of facility policy, medical record (MR) and staff interview (EMP), it was determined the facility failed to evaluate the nursing care for one of 11 medical records reviewed (MR1). Findings include: A review of facility policy "Children's Hospital Standard of Care" effective December 2016, revealed, "...f. Ongoing patient assessment includes the following: Vital Signs...Temperature...For heating/cooling devices: Minimum of every 2 hours when a patient is under a heating lamp, warming blanket, or cooling blanket. If not contraindicated, patients requiring warming/cooling blanket should have continuous temperature monitoring rectal or foley probe in place...." A review on April 12-13, 2017, of MR1 revealed the patient arrived in the Emergency Department on January 10, 2017, at 2:51 PM, with a temperature of 89.4 degrees F, rectally. A Bair Hugger (blanket warmer device) was applied to the patient. The following patient temperatures were obtained rectally: 90.8 F at 8:16 PM, 92.8 F at 9:14 PM, 97.8 at 10:44 PM, and 98.0 F at 12:14 AM on January 11, 2017. There were no other temperatures documented until 10:22 AM on January 11, 2017. The patient's rectal temperature at that time was 107.6 F. A review of physician inpatient note addendum dated January 13, 2017, revealed "...We came and saw him in ED around 10 AM. There were no vitals and his last temp was around midnight. The nurse during the rounds told us him temp was now 42 C {107.6 F}. We asked about the bair hugger and it had been on high all night. ..." An interview conducted on April 13, 2017, at 9:40 AM with EMP19 confirmed that the temperatures were not documented in the patient's medical record. EMP19 stated "I know I took temps. I was in the room every hour doing eye drops. I must have not documented, I did not have the computer with me. I was probably busy with something else." An interview conducted on April 12, 2017, at 10:45 AM with EMP4 confirmed that no temps were documented for a "10 hour period." |
||
| VIOLATION: PATIENT CARE ASSIGMENTS | Tag No: A0397 | |
| Based on review of facility documents, personnel file (PF), and staff interview (EMP), it was determined that the facility failed to ensure that the employee received orientation/training on the thermoregulation technique and devices for one of three personnel files reviewed (PF3). Findings include: A review of facility Emergency Department Registered Nurse Core Competency on April 12, 2017, revealed "...Integumentary/Surface Trauma Competency Statement: Demonstrate or verbalized an ability to assess, identify, provide care, manage, and troubleshoot potential or actual life-threatening integumentary/surface trauma emergencies and associated equipment. ...4. Thermoregulation techniques & devices - cooling machine/Bear {sic} hugger." Further review of the competency form revealed, "This form is to be completed within the allotted hours for orientation at PSHMC." A review of PF3 on April 12, 2017, revealed the Emergency Department Registered Nurse Core Competency was not complete. The Thermoregulation techniques & devices - cooling machine/Bear {sic} hugger was not signed off as completed. Further review of PF3 revealed the employee was hired on April 19, 2016. An interview conducted on April 13, 2017, at 9:30 AM with EMP4 confirmed the nurse core competency was not completed for thermoregulation techniques & devices - cooling machine/Bair Hugger for PF3 and that the employee was hired one year ago. |
||
| VIOLATION: SUPERVISION OF CONTRACT STAFF | Tag No: A0398 | |
| Based on review of facility policy, personnel files (PF), and staff interview (EMP), it was determined the facility failed to ensure periodic work performance evaluations were completed for one of three personnel files reviewed (PF1). Findings include: A review of facility policy "Agency Personnel" effective October 2015, revealed, "...b. {name redacted} Healthcare will send an evaluation form, six weeks after the agency personnel has worked on the unit. Evaluation form will be completed electronically by the Nurse Manager or designee and submitted to {name redacted} Healthcare. Evaluation is kept on file by {name redacted} Healthcare. ..." A review of PF3 on April 12, 2017, revealed the employee was hired on April 19, 2016. There were no evaluations in the personnel file. An interview conducted April 13, 2017, at 9:20 AM with EMP18 confirmed that no evaluations were done for PF3. EMP18 further confirmed that the facility should have done 3 evaluations, at least 6 weeks apart, for PF3. |
||
| VIOLATION: FORM AND RETENTION OF RECORDS | Tag No: A0438 | |
| Based on review of facility policy, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure all clinical information pertaining to a patient shall be completely and accurately incorporated in the medical record for one of 11 medical records reviewed (MR1). Findings include: A review of facility policy "Children's Hospital Standard of Care" effective December 2016, revealed, "...f. Ongoing patient assessment includes the following: Vital Signs...Temperature...For heating/cooling devices: Minimum of every 2 hours when a patient is under a heating lamp, warming blanket, or cooling blanket. If not contraindicated, patients requiring warming/cooling blanket should have continuous temperature monitoring rectal or foley probe in place...." A review on April 12-13, 2017, of MR1 revealed the patient arrived in the Emergency Department on January 10, 2017, at 2:51 PM, with a temperature of 89.4 degrees F, rectally. A Bair Hugger (blanket warmer device) was applied to the patient. The following patient temperatures were obtained rectally: 90.8 F at 8:16 PM, 92.8 F at 9:14 PM, 97.8 at 10:44 PM, and 98.0 F at 12:14 AM on January 11, 2017. There were no other temperatures documented until 10:22 AM on January 11, 2017. The patient's rectal temperature at that time was 107.6 F. A review of physician inpatient note addendum dated January 13, 2017, revealed "...We came and saw him in ED around 10 AM. There were no vitals and his last temp was around midnight. The nurse during the rounds told us him temp was now 42 C {107.6 F}. We asked about the bair hugger and it had been on high all night. ..." An interview conducted on April 13, 2017, at 9:40 AM with EMP19 confirmed that medical record documentation was not complete due to the failure to include the patient's temperatures. EMP19 stated "I know I took temps. I was in the room every hour doing eye drops. I must have not documented, I did not have the computer with me. I was probably busy with something else." An interview conducted on April 12, 2017, at 10:45 AM with EMP4 confirmed that no temps were documented for a "10 hour period." |
||
| VIOLATION: CONTENT OF RECORD - OTHER INFORMATION | Tag No: A0467 | |
| Based on review of facility policy, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure clinical information pertaining to the patient's condition was consistently documented in the medical record for one of 11 medical records reviewed (MR1). Findings include: A review of facility policy "Children's Hospital Standard of Care" effective December 2016, revealed, "...f. Ongoing patient assessment includes the following: Vital Signs...Temperature...For heating/cooling devices: Minimum of every 2 hours when a patient is under a heating lamp, warming blanket, or cooling blanket. If not contraindicated, patients requiring warming/cooling blanket should have continuous temperature monitoring rectal or foley probe in place...." A review on April 12-13, 2017, of MR1 revealed the patient arrived in the Emergency Department on January 10, 2017, at 2:51 PM, with a temperature of 89.4 degrees F, rectally. A Bair Hugger (blanket warmer device) was applied to the patient. The following patient temperatures were obtained rectally: 90.8 F at 8:16 PM, 92.8 F at 9:14 PM, 97.8 at 10:44 PM, and 98.0 F at 12:14 AM on January 11, 2017. There were no other temperatures documented until 10:22 AM on January 11, 2017. The patient's rectal temperature at that time was 107.6 F. A review of physician inpatient note addendum dated January 13, 2017, revealed "...We came and saw him in ED around 10 AM. There were no vitals and his last temp was around midnight. The nurse during the rounds told us him temp was now 42 C {107.6 F}. We asked about the bair hugger and it had been on high all night. ..." An interview conducted on April 13, 2017, at 9:40 AM with EMP19 confirmed that the medical record failed to include documentation of the patient's temperatures. EMP19 stated "I know I took temps. I was in the room every hour doing eye drops. I must have not documented, I did not have the computer with me. I was probably busy with something else." An interview conducted on April 12, 2017, at 10:45 AM with EMP4 confirmed that no temps were documented for a "10 hour period." |
||
| VIOLATION: EMERGENCY SERVICES | Tag No: A1100 | |
| Based on review of facility policy, medical record (MR) and staff interview (EMP), it was determined the facility failed to meet the emergency needs of a patient in accordance with acceptable standards of practice for one of 11 medical records reviewed (MR1). Findings include: A review of facility policy "Children's Hospital Standard of Care" effective December 2016, revealed, "...f. Ongoing patient assessment includes the following: Vital Signs...Temperature...For heating/cooling devices: Minimum of every 2 hours when a patient is under a heating lamp, warming blanket, or cooling blanket. If not contraindicated, patients requiring warming/cooling blanket should have continuous temperature monitoring rectal or foley probe in place...." A review on April 12-13, 2017, of MR1 revealed the patient arrived in the Emergency Department on January 10, 2017, at 2:51 PM, with a temperature of 89.4 degrees F, rectally. A Bair Hugger (blanket warmer device) was applied to the patient. The following patient temperatures were obtained rectally: 90.8 F at 8:16 PM, 92.8 F at 9:14 PM, 97.8 at 10:44 PM, and 98.0 F at 12:14 AM on January 11, 2017. There were no other temperatures documented until 10:22 AM on January 11, 2017. The patient's rectal temperature at that time was 107.6 F. A review of physician inpatient note addendum dated January 13, 2017, revealed "...We came and saw him in ED around 10 AM. There were no vitals and his last temp was around midnight. The nurse during the rounds told us him temp was now 42 C {107.6 F}. We asked about the bair hugger and it had been on high all night. ..." An interview conducted on April 13, 2017, at 9:40 AM with EMP19 confirmed that the temperatures were not documented in the medical record. EMP19 stated "I know I took temps. I was in the room every hour doing eye drops. I must have not documented, I did not have the computer with me. I was probably busy with something else." An interview conducted on April 12, 2017, at 10:45 AM with EMP4 confirmed that no temps were documented for a "10 hour period." |
||
| VIOLATION: EMERGENCY SERVICES POLICIES | Tag No: A1104 | |
| Based on a review of facility policy, medical records (MR), manufacturer guidelines, and staff interviews (EMP) it was determined the facility failed to ensure their policy related to Bair Hugger warming device matched the manufacturer guidelines. Findings include: A review of facility policy "Children's Hospital Standard of Care" effective December 2016, revealed, "...f. Ongoing patient assessment includes the following: Vital Signs...Temperature...For heating/cooling devices: Minimum of every 2 hours when a patient is under a heating lamp, warming blanket, or cooling blanket. If not contraindicated, patients requiring warming/cooling blanket should have continuous temperature monitoring rectal or foley probe in place...." A review on April 12-13, 2017, of MR1 revealed the patient arrived in the Emergency Department on January 10, 2017, at 2:51 PM, with a temperature of 89.4 degrees F, rectally. A Bair Hugger (blanket warmer device) was applied to the patient. The following patient temperatures were obtained rectally: 90.8 F at 8:16 PM, 92.8 F at 9:14 PM, 97.8 at 10:44 PM, and 98.0 F at 12:14 AM on January 11, 2017. There were no other temperatures documented until 10:22 AM on January 11, 2017. The patient's rectal temperature at that time was 107.6 F. A review of warming device manufacturer's guidelines revealed, "...Precautions. Monitor the patient's temperature at least every 10-20 minutes, and monitor the patient's vital signs regularly. Reduce air temperature or discontinue therapy when the therapeutic goal is reached or it vital sign instability occurs. ..." An interview conducted on April 13, 2017, at 12:15 PM with EMP26 confirmed the facility did not follow the manufacturer's guidelines, but should have. EMP26 was not aware of the manufacturer guideline regarding monitoring the temperature at least every 10-20 minutes. EMP26 stated, "It was news to me." |
||