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.

MOUNT NITTANY MEDICAL CENTER 1800 EAST PARK AVE STATE COLLEGE, PA 16803 Dec. 31, 2013
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of facility documents and interview with staff (EMP), it was determined that Mount Nittany Medical Center failed to ensure that patients at the Surgical Center received care in a safe setting.

Findings include:

A review of "Mount Nittany Surgical Center, Patient Rights & Responsibilities," revealed, " ... Informed Decisions. You have the right to: ... Be informed about proposed care options including the risks and benefits, other care options, what could happen without care, and the outcome(s) of any medical care provided, including any outcomes that were not expected. ... Care Delivery. You have the right to: ... Receive care in a safe setting free from any form of abuse, harassment, and neglect. Receive kind, respectful, safe, quality care delivered by skilled staff. ... Receive efficient and quality care with high professional standards that are continually maintained and reviewed. ... ."

A review of Mount Nittany Surgical Center policy entitled, Surgical Treatment, Site Identification 5013, reviewed September 13, 2013, revealed, "... Policy statement: It is the policy of Mount Nittany Medical Center that all surgical, radiation oncology, radiology, special procedure, biopsy, and other invasive procedure and treatment sites where there is laterality, multiple structures, or multiple levels shall be uniformly marked on the patient. For procedures that involve laterality of organs but the incision(s) or approached may be from the mid-line or from a natural orifice, the site is still marked and the laterality noted. This policy does not apply to single organ cases; interventional cases for which the catheter or instrument insertion site is not predetermined; teeth; or premature infants, for whom marking may cause a permanent tattoo. The only exception to this policy is for those procedures where the physician performing the procedure is in continuous attendance with the patient from the time of decision to do the procedure and consent has been obtained from the patient or guardian through the conduct of the procedure. Medical Center-Wide Procedures: 1. The physician performing the procedure prior to the patient receiving any type of sedation or medication that would impede his or her ability to concur that the correct site has been identified and prior to the patient being moved to where the procedure will be performed shall mark the correct procedure site with the physician's initials. For minors and those patients who are unable to verify the correct site, a legal guardian, parent, or family member may concur that the correct site is being identified. 2. Make the mark at or near the incision site. DO NOT mark any non-operative site(s) unless necessary for some other aspect of care. 3. The mark shall be the physician's initials. 4. The mark will be positioned to be visible after the patient is prepped and draped. 5. The mark should be made using a marker that is sufficiently permanent to remain visible after completion of the skin prep. The use of stickers shall be avoided, as inadvertent removal is possible. 6. Verification of the marked site shall take place during the 'time out' as per the Time Out Policy ... ."

1. MR1 contained a Consent for right hand, long and ring finger, trigger releases. The postoperative diagnosis revealed trigger finger release of the right long, ring, and index fingers.
MR1 contained an Operative Report, " ... When I went to do my dictation I noted that we had on the permit the ring finger. I went into the room and spoke with the patient, who was awake now. We moved the patient back over and completed the ring finger. ... ."

2. MR2 contained a Patient Reservation form, " ... Provisional Diagnosis: Left shoulder rotator cuff tear ... Surgery/Procedure: Left shoulder rotator cuff repair subacromial decompression ... Estimated Case Length: 2 hours ... Operative Times: Patient In: 1207 on 09/13/13. Procedure Start: 1243 on 09/13/13. Procedure End: 1428 on 09/13/13. Patient Out: 1432 on 09/13/13. ... ."
Further review of MR2 revealed no documentation that the surgeon left the OR while the patient remained under anesthesia, for approximately 40 minutes.
3. An interview was conducted with EMP1 on November 15, 2013, at 9:15 AM. EMP 1 confirmed that the same surgeon that performed surgery on the wrong finger also left a patient under anesthesia for 40 minutes while they went and saw another patient in the office.
4. An interview was conducted with EMP9 on November 15, 2013, at 11:00 AM. "The scope was already in the patient. The staff was standing around waiting for the physician to return. EMP1 had to call the office and request they come back to surgery. It is understood that physicians do not leave the Operating Room ... ."
5. An interview was conducted with EMP6 on November 8, 2013, at approximately 9:35 AM. "Draping is performed in the Operating Room. The sight marking was on the patient's mid forearm which would have been covered by the drapes. Ideally the sight should be marked on the finger that the surgery is going to be performed on. ... ."
VIOLATION: QAPI Tag No: A0263
Based on a review of facility documents and staff interviews (EMP), it was determined that Mount Nittany Medical Center failed to implement and maintain an effective, ongoing, hospital-wide, data-driven Quality Assessment and Performance Improvement Program by failing to measure and analyze quality indicators for all hospital Departments (A0267), by failing to collect data in order to monitor the effectiveness and safety of services and quality of care (A0275), and by failing to identify opportunities for improvement and changes that would lead to improvement (A0276).

Findings include:

Review of "Amended and Restated Bylaws of Mount Nittany Medical Center" amended April 29, 2013, revealed, "Mount Nittany Medical Center as Other Body: As set forth in articles of incorporation and/or Bylaws of Mount Nittany Surgical Center, Inc. and the ... this Corporation shall have all of the rights of an "other body," as such term is defined by the NPCL. In addition, this Corporation shall have such other powers with respect to Mount Nittany Surgical Center, Inc. and the ... have been reserved to this Corporation in the respective Bylaws and/or Articles of each entity. ... Article VI. Quality Improvement. Section 6.1. Quality and Performance Improvement Program: The Board shall adopt a facility wide Quality and Performance Improvement program designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient care and clinical performance, pursue opportunities to improve patient care, and other services provided by this Corporation, and resolve identified problems ... ."

Review of "Mount Nittany Medical Center, Organizational Plan for Performance Improvement," approved April 30, 2013. "Purpose: The purpose of this Plan is to provide a framework for performance improvement that ensures well-designed Medical Center processes and provides for systematically monitoring, analyzing and improving performance to improve patient outcomes. The performance improvement process is designed to continually assess and meet customer expectations, prevent problems, and build a commitment to quality. ... Performance Improvement Nurses: Performance Improvement nurses are responsible for the following activities under the direction of the Vice President for Quality/Patient Safety Officer: a) conducting concurrent surveillance and medical record review to identify issues related to quality of care; b) reviewing medical records in preparation for peer review activities ... ."

Review of "Agreement For Medical Records Services" made and effective as of the first day of July, 2000, revealed, "... by and between the CENTRE COMMUNITY SURGICAL CENTER, Inc., ... and CENTRE COMMUNITY HOSPITAL ... (hereinafter "CONTRACTOR'). ... 1. Services 1.1 CONTRACTOR shall function as an independent contractor and be a provider of Medical Record services to CCSC. Such services shall include: ... 1.2 CONTRACTOR shall regularly perform and timely provide to CCSC the results of all Quality Assurance and Quality Improvement studies and activities performed in relation to the services provided under this Agreement. 1.3 CONTRACTOR shall provide to CCSC a complete set of policies and procedures of CONTRACTOR pertaining to the services provided under this Agreement and shall timely maintain and update such policies and procedures during the term of this Agreement. 1.4 CONTRACTOR's employees shall be present in CCSC facilities and shall consult with CCSC in proper cases, and during such hours as CCSC shall determine to be necessary and appropriate ... ."

1. A review of Mount Nittany Medical Center, "Health Information Management Committee Meeting Minutes" dated January 9, 2013 thru October 13, 2013, revealed no documented evidence of discussion related to the Surgical Center. (A0267)

2. A review of Mount Nittany Medical Center Quality data related to medical record reviews, revealed no documented evidence that the Surgery Center was included in such data. (A0267)

3. An interview was conducted with EMP15 on December 13, 2013, at 11:40 AM. "I do not do any Quality of the Surgical Center's records. They do their own chart reviews at the Surgical Center. I was not aware that the contract stated that our Department was to do it." (A0275)

4. Review of Mount Nittany Medical Center Quality Council meeting minutes dated January 17, 2013, to present revealed no evidence of discussion related to a physician leaving the Operating Room for approximately forty minutes, after case was initiated while a surgical patient remained under anesthesia. (A0276)