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.

ALLEGHENY VALLEY HOSPITAL 1301 CARLISLE ST NATRONA, PA 15065 Oct. 10, 2018
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of facility policy and procedure, medical records (MR), and interview with staff (EMP), it was determined the facility failed to use restraints in accordance with the order of a physician for three of seven medical records reviewed (MR1, MR2 and MR3.)

Findings include:

Review of facility policy and procedure "Restraint and Seclusion" last revised September 2018, revealed "The use of restraint or seclusion must be: ... C. In accordance with the order of a physician or other licensed independent practitioner, who is responsible for the care of the patient (but not a standing or PRN order). The individual ordering the restraint or seclusion must have a working knowledge of this policy and procedure on restraints and seclusion. ... 5. The restraint order will include a. the date/time of order b. indication for restraint, c. type of restraint and d. duration of restraint order."
1. Review of MR1's Seclusion Flowsheet Psychiatric Department (ED) dated September 18, 2018, revealed documentation at 1845 "Patient viewed via seclusion room window q (every) 15 minutes" with an X and a staff initial next to the box that indicated patient was placed into seclusion.
2. A subsequent review of physician ED orders from September 18, 2018, at 1841 through September 19, 2018, at 1849 revealed no physician orders were written for seclusion.
Interview with EMP1 on September 28, 2018 at approximately 10:00 AM confirmed the above findings and revealed after interviews with CF1, CF2, and CF3 none of the physican's wrote an order for seclusion.
3. Review of MR2 revealed a physician order " 02/27/18 1745 Restrain Pt[patient] due to escalating behavior and loss of physical control with use of leather restraints. Further review revealed no documentation of the exact type to include wrist, ankle, left, right, or four point.

4. Review of MR3 revealed a physician order " 02/27/18 1745 Restrain Pt[patient] due to escalating behavior and loss of physical control with use of leather restraints. Further review revealed no documentation of the exact type to include wrist, ankle, left, right, or four point.

Interview with EMP2 on September 28, 2018, at approximately 10:45 AM confirmed the above findings.
VIOLATION: PATIENT RIGHTS Tag No: A0115
The CONDITION is not met as evidenced by:
Based on the systemic nature of the standard-level deficiencies related to patient rights, the facility staff failed to substantially comply with this condition.

The findings were:

These following standards were cited and show a systemic nature of non-compliance with regards to patient's rights as follows:

(482.13 Tag A-0144)
The information reviewed during the survey provided evidence that one of seven patients sampled for a review of restraint use (MR5) was not afforded a standard of care consistent with professionally recognized standards of nursing practice.

(482.13 Tag A-0145)
The information reviewed during the survey provided evidence that one of 10 patients sampled for a review of abuse (MR1) was verbally and physically abused by one or more of the facility's staff.

(482.13 Tag A-0154)
The information reviewed during the survey provided evidence that two of seven patients sampled for a review of restraint use (MR5 and MR8) were placed in restraints and seclusion for staff convenience and not for the concern of the immediate physical safety of the patient, staff or others.

(482.13 Tag A-0164)
The information reviewed during the survey provided evidence that five of seven patients sampled for a review of restraint use (MR2, MR3, MR4, MR5, and MR6) were not considered for least restrictive interventions prior to being placed in restraints or seclusion.

(482.13 Tag A-0168)
The information reviewed during the survey provided evidence that three of seven patients sampled for a review of restraint use (MR1, MR2, and MR3) were placed in restraints and/or seclusion without a physician order.

(482.13 Tag A-0174)
The information reviewed during the survey provided evidence that three of seven patients sampled for a review of restraint use (MR2, MR3, and MR5) failed to have their restraints or seclusion discontinued at the earliest possible time.

(482.13 Tag A-179)
The information reviewed during the survey provided evidence that four of seven patients sampled for a review of restraint use (MR1, MR4, MR5, and MR6) failed to have a face-to face conducted by a physician or a Licensed Independent Practioner (LIP) within one hour after being placed in restraints or seclusion.

(482.13 Tag A-184)
The information reviewed during the survey provided evidence that four iof seven patients sampled for a review of restraint use (MR1, MR4, MR5, and MR6) revealed no documentation of a face-to-face being completed by a physician or a Licensed Independent Practioner (LIP) within one hour after being placed in restraints or seclusion.

(482.21 Tag A-0297)
The information reviewed during the survey provided evidence that the facility failed to complete a quality project regarding the use of restraint and seclusion.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of facility documentation, medical record (MR), and staff interview (EMP), it was determined that the facility failed to follow nursing care policies and procedures consistent with professionally recognized standards of nursing practice for one of seven medical records reviewed (MR5).

Findings include:

Review of facility policy and procedure "Restraint and Seclusion" lasted revised September 2018, revealed "Monitoring & Documentation. While the patient is in restraints, it is incumbent upon the nursing staff to meet the patient's basic comfort, safety, and personal needs through monitoring and interventions. ... Based upon the restraint method used, assessment, monitoring and interventions may include: ... G. Toileting"

Review of MR5 revealed the patient was placed in seclusion on August 11, 2018, at 5:21 PM. Further review revealed documentation from 6:00 PM though 10:00 PM patient was calm, resting quietly, laying on mat, etc. Continued review revealed no documentation the patient was offered toileting. At 10:00 PM documentation revealed "Pt asked to use BR(bathroom)- unable to wait used cup."

Interview with EMP1 on October 1, 2018, at approximately 1:15 PM confirmed the above findings.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on a review of facility documentation, medical records (MR) and staff interviews (EMP), it was determined the facility failed to safeguard patients from all forms of harm and abuse for one of 10 medical records reviewed (MR1).

Findings include:


Review of facility policy "Patient Bill of Rights and Responsibilities, 300-RI-020, last revised 11-2017 revealed,'...A patient has the right to be free from all forms of abuse or harassment... ."


Review of facility policy "Allegation of Patient Abuse" last revised 4/2018 revealed "... [The facility] values respect and dignity and therefore, prohibits all forms of patient abuse...Abuse includes verbal, mental, physical, and sexual abuse...Abuse: intentional mistreatment or the willful infliction of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm, pain, or mental anguish...Abuse can be mental, physical, or sexual...Physical Abuse/Harm: intentional mistreatment of an individual that may cause physical injury... ."


Review of MR1 Multidisciplinary Notes Psychiatric Unit dated September 21, 2018, at 1955 revealed "...patient back from x-ray via w/c (wheelchair). Denies hearing voices to writer denies suicidal thoughts, reports did not sleep well last night. C/O (complaint of) rib pain and abd (abdomen) pain doc called for order for x-ray to be done...Reported to writer in ER (emergency room )...was 'roughed up by staff and security."...bruising on (both) arms and (both) legs also per RN (Registered Nurse)...on rib area...Pt. (patient) spoke to charge RN concerning her ER complaint also notified nursing supervisor of pt. complaint... .

Review of MR1's Department of Medical Imaging Report dated September 21, 2018, at 7:38 PM revealed "...Findings: There are fractures of the left 6th and 7th ribs in the axillary line... ."

Interview conducted with MR1 on October 1, 2018 at approximately 10:00 AM revealed "This happened two weeks ago. I was brought in by the police. I was intoxicated and not the best patient. I was taken to a treatment room in the ED, had vital signs taken. I was not being belligerent. A nurse taken came in and was not nice. We began to shout at each other. The nurse called security. There were at least four guards. They dragged me into the seclusion room put me on a concrete floor took away the mattress and put me there. Told me they were going to take blood from me. I told them I have had veins and have trouble with blood draws. The nurse said they needed more blood. I told them last year I had surgery, I was stuck 37 times to get an IV (intravenous) in me. The nurse said she would hold me down. He/she sat on my hip it was painful, I then twisted and got on my back. I kept telling her that he/she was hurting me. My arm was bleeding after that. I was wearing street clothes. I was told to put on a gown. The nurse threatened to rip my clothes off if I did not change. I refused to remove my clothes with the security guards there in the room. An aide did help me get out of my clothes and into the gown. Later I had to urinate. I was banging on the door hoping someone would let me go to the bathroom. My hands were bleeding from banging on the door. No one would help me, so I had to pee on the floor. I finally got the attention of a nurse, he/she called me a filthy pig. I was angry and agitated. They were going to give me a shot. The first nurse sat on my left side. I was drunk, they were going to give me a shot in my hip. the security guard was holding my neck. I told them I had a hip replacement one year ago. The nurse refused to give me the mattress back. I woke up on the mattress with a blanket...I was x-rayed on the right side and there were no issues. I still had pain, then they x-rayed my left side and it showed the fractures... ."

Interview conduced with EMP3 on October 1, 2018, at approximately 10:30 AM revealed,"...The patient was moved to seclusion because of behavior, still handcuffed, waiting to draw blood. the blood was taken from the patient. [EMP10] and the patient were being verbally abusive back and forth. I said, be adults especially the nurse. Took the patient to room 20, took the mattress out of the room... ."

Interview conducted with EMP4 on October 1, 2018, at approximately 11:30 AM revealed "...when I was there we did move patient into seclusion. Did try to get blood work, was not able to get blood work the first time. Patient was held down to get the blood work. someone was holding feet, someone was holding [MR1] wrists and also [MR1] chest. Security was holding legs. The patient wrestled on the floor. the doctor ordered meds for the patient. The nurse gave the medication. the nurse was laying across the abdomen."

Interview with EMP6 on October 1, 2018, at approximately 12:30 PM revealed " The patient was brought into room 18, continued to be combative calling [EMP3] names. The patient was kicking us, refused to cooperate with changing clothes...the patient continue to call nurse vulgar names...We took the mattress out for a while, it was put back in later. the patient did calm down for a bit but when they wanted more blood again [MR1] began escalating and yelling, did not want blood drawn. Punched security guard in the mouth. We held [MR1] arms the...[facility] police, [local] police and the security staff held down the patient's arm until the blood was drawn. We tried to settle [MR1] down but was still upset. EMP10 argued with the patient. The patient called (EMP10) a cunt. [EMP10] told [MR1] I am not a cunt you are. We took the mattress out of the seclusion room because the charge nurse told us to, so the patient could not throw it at us.

Interview conducted on October 1, 2018, at approximately 1:30 PM revealed "...The patient was very intoxicated, very vulgar. We went to get bloodwork. We had to hold [MR1] own. I had the feet, security had the patient's head and [MP10] as holding the patient down by being on top of the patient."
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on review of facility documentation, medical records (MR), and staff (EMP) interview revealed the facility permitted the use of a chain type restraint (hand cuffs) typically employed as a law enforcement intervention and failed to ensure restraint or seclusion was only imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time for two of seven medical records reviewed (MR5 and MR8).

Findings include:

Review of facility policy and procedure "Restraint and Seclusion" last revised September 2018, revealed "All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restrain or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and should be discontinued at the earliest possible time...Forensic Restraints-The use of handcuffs, manacles, shackles, other chain-type restraint devices and leather cuffs are considered law enforcement restraint devices and are not considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients. They may be used by law enforcement officials for custody, detention and public safety reasons and are not governed by this policy. Law enforcement officers who maintain custody and direct supervision of prisoners (the hospital's patients) are responsible for the use, application and monitoring of these devices in accordance with federal and state law..."

1. Review of MR8 on September 21, 2018, revealed 9-18-18 1215...(MR8) sat on floor handcuffs placed on (MR8)... Patient then placed in wheelchair. Taken back to seclusion with Security Officers present and House Police present handcuffs removed at this time..."

Interview with EMP1 on October 1, 2018, at approximately 9:00 AM confirmed handcuffs were used as a non-law enforcement intervention and revealed "I told them...once he went to his knees he no longer resisted, you should not have put the cuffs on (MR8)..."

2. Review of MR5 on October 1, 2018, revealed "Seclusion Flowsheet ... 8-11-18 1721 ... pt placed in Seclusion by staff D/T[due to] being uncooperative with staff". Further review of MR5 revealed no documentation that indicated a risk for the immediate physical safety of the patient, a staff member, or others.

Interview with EMP2 on October 1, 2018, at approximately 10:30 AM confirmed the above findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
Based on review of facility policies and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure less restrictive interventions were determined to be ineffective, prior to the application of a restraint or seclusion, for five of seven restraint medical records reviewed (MR2, MR3, MR4, MR5 and MR6).

Findings include:

Review of facility policy and procedure "Restraint and Seclusion" last revised September 2018, revealed "Restraint and seclusion will be based upon the assessed needs of the patient after appropriate assessment has been performed. Their use will be limited to those situations where alternatives and less restrictive interventions have proven to be ineffective in preventing the patient from causing physical harm to him/her or others or pose a serious threat of damage to the treatment environment ... Least Restrictive Intervention Measures which provide for safety and protection from harm while allowing the maximum amount of freedom and movement."
1. Review of MR2, revealed a physician order "02/27/18 1745 Restraint Pt due to escalating behavior and loss of physical control with use of leather restraints" Further review revealed no documentation that less restrictive interventions were attempted prior to application of a restraint.
2. Review of MR3, revealed a physician order "08/01/18 1223 Leather Restraints" Further review revealed no documentation that less restrictive interventions were attempted prior to application of a restraint.
3. Review of MR4, revealed a physician order "08/24/18 0347 Seclusion" Further review revealed no documentation that less restrictive interventions were attempted prior to seclusion.
4. Review of MR5, revealed a physician order "08/11/18 1721 Seclusion" Further review revealed no documentation that less restrictive interventions were attempted prior to seclusion.
5. Review of MR6, revealed a physician order "08/27/18 1858 Seclusion" Further review revealed no documentation that less restrictive interventions were attempted prior to seclusion.
Interview with EMP2 on September 28, 2018, at approximate 10:45 AM confirmed the above findings and revealed "I'm not seeing the documentation."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0170
Based on a review of facility documentation, medical records (MR) and staff interview, it was determined the facility failed to obtain a physician order for seclusion as soon as possible after the patient was placed in seclusion for one of seven medical records reviewed. (MR1)

Findings include:

Review of facility policy "Restraint and Seclusion" last revised 9/2018 revealed "...Restraint and Seclusion Standard for the Management of Violent/Self Destructive Behavior...2. In the case of an emergency, the restraint/seclusion can be initiated by an RN while a stat page is placed to notify the physician of a change in the patient's condition and to obtain an order..."

1. Review of MR1's Seclusion Flowsheet Psychiatric Department (ED) dated 9/18/18 revealed documentation at 1845 "Patient viewed via seclusion room window q (every) 15 minutes" with an X and a staff initial next to the box that indicated patient was placed into seclusion.
2. A subsequent review of physician ED orders from 9/18/18 at 1841 through 9/19/18 at 1849 revealed no physician orders were written for seclusion.
Interview with EMP1 on 9/28/18 at approximately 10:00 AM confirmed the above findings and revealed after interviews with CF1, CF2, and CF3 none of the physicans wrote an order after MR1 was placed in seclusion by staff because they were never notified by staff.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to discontinue restraints at the earliest possible time for three of seven medical records reviewed (MR2, MR3, and MR5.)

Findings include:

Review of facility policy and procedure "Restraint and Seclusion" last revised September 2018, revealed "The use of restraint or seclusion must be discontinued at the earliest possible time based on an individualized patient assessment and re-evaluation"
1. Review of MR2 revealed the patient was placed in restraints on February 27, 2018, at 5:45 PM. Further review revealed documentation the patient was sleeping from 6:30 PM until 7:45 PM. At 8:00 PM to 8:30 PM documentation revealed the patient was awake and cooperative. At 8:45 PM documentation revealed "Pt. out of restraints dressing in Hospital cloths. Back in restraints." Continued review revealed documentation from 9:00 PM until 9:45 PM the patient was awake and quiet.
2. Review of MR3 revealed the patient was placed in restraints on August 1, 2018, at 12:00 PM. Further review revealed documentation at 1300 "Pt Alert talking with case worker and watching TV, 1320 "Labs collected" Continued review from 1400 through 1700 revealed documentation the patient was cooperative or sleeping.
3. Review of MR5 revealed the patient was placed in Seclusion on August 11, 2018, at 5:21 PM. Further review revealed documentation from 6:00 PM thru August 12, 2018, at 06:00 AM patient was resting quietly, patient lying on mat, or patient sleeping.
Interview with EMP1 on September 28, 2018, at approximately 9:55 AM confirmed the above findings and revealed "I see that, they(patients) should have came out."
Interview with EMP2 on September 28, 2018, at approximate 10:45 AM confirmed the above findings and revealed "I'm not seeing the documentation to keep them(patient's) in."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that the patient was seen face-to-face within one hour after the initiation of the intervention to evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the restraint or seclusion for three of seven medical records reviewed (MR1,MR4, MR5 and MR6).


Findings include:


Review of facility policy and procedure "Restraint and Seclusion" last reviewed September 2018, revealed "Face To-Face Assessment The face-to-face assessment includes an evaluation of the patient's immediate situation, the patient's reaction to the intervention, the patient ' s medical and behavioral condition and the need to continue or terminate the restraint or seclusion. ... The purpose of the face-to-face assessment is to complete a comprehensive review of the patient's condition to determine if other factors, such as drug or medication interactions, electrolyte imbalances, hypoxia, and sepsis are contributing to the patient's violent or self-destructive behavior."
1. Review of MR1's Seclusion Flowsheet Psychiatric Department (ED) dated September 18, 2018, revealed documentation at 1845 "Patient viewed via seclusion room window q (every) 15 minutes" with an X and a staff initial next to the box that indicated patient was placed into seclusion.
2. Further review of MR1 reviewed no documentation a face-to-face assessment was completed.
3. Review of MR4 revealed a physician order "08/24/18 0357 Seclusion" further review revealed no documentation the face-to-face assessment was initiated within one hour.
4. Review of MR5 revealed a physician order "08/11/18 1721 Seclusion" further review revealed no documentation the face-to-face assessment was initiated within one hour.
5. Review of MR6 revealed a physician order "08/27/18 1858 Seclusion" further review revealed no documentation the face-to-face assessment was initiated within one hour.
Interview with EMP1 on October 1, 2018, at approximately 1:20 PM confirmed the above findings and revealed "No they are not doing it[face to face assessment]."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0184
Based on a review of facility documentation, medical records (MR) and staff interview (EMP), it was determined the facility failed to document evidence a face-to-face evaluation for restraints or seclusion used to manage patients violent of self-destructive behavior for four of seven medical records reviewed (MR1, MR4, MR5, and MR6).

Findings include:

Review of facility policy and procedure "Restraint and Seclusion" last reviewed September 2018, revealed "Face To-Face Assessment: The face-to-face assessment includes an evaluation of the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the restraint or seclusion. ... The purpose of the face-to-face assessment is to complete a comprehensive review of the patient's condition to determine if other factors, such as drug or medication interactions, electrolyte imbalances, hypoxia, and sepsis are contributing to the patient's violent or self-destructive behavior."

Review of MR1's Seclusion Flowsheet Psychiatric Department (ED) dated 9/18/18 revealed documentation at 1845 "Patient viewed via seclusion room window q (every) 15 minutes" with an X and a staff initial next to the box that indicated patient was placed into seclusion.

A further review of MR1's revealed no documentation of a face to face being being documented in MR1.

During interview on 9/29/18 at approximately 10:00 AM EMP 1 confirmed the above findings.


Review of MR4 revealed a physician order "08/24/18 0357 Seclusion" further review revealed no documentation the face-to-face assessment was initiated within one hour.

Review of MR5 revealed a physician order "08/11/18 1721 Seclusion" further review revealed no documentation the face-to-face assessment was initiated within one hour.

Review of MR6 revealed a physician order "08/27/18 1858 Seclusion" further review revealed no documentation the face-to-face assessment was initiated within one hour.

Interview with EMP1 on October 1, 2018, at approximately 1:20 PM confirmed the above findings and revealed "No they are not doing it [face to face assessment]."
VIOLATION: QAPI PERFORMANCE IMPROVEMENT PROJECTS Tag No: A0297
Based on review of facility policy and documents and staff interview (EMP), it was determined that the facility failed to document the restraint quality improvement projects outcome.

Findings include:

Review of facility documentation "Quality Improvement Plan CY 2018" revealed "Information gathered from the following assessment tools are integrated and presented to the PIOS (Performance Improvement Oversight Committee) for review and evaluation: ... Departmental Quality Improvement Reports ... The PIOC reviews data provided by the Network Quality Team, and by clinical and operational departments and services throughout the hospital."

Review of facility policy and procedure "Restraint and Seclusion" revised September 2018, revealed "Quality Assessment/Performance Improvement..Hospital leadership is responsible for creating a culture that supports a patient's right to be free from restraint or seclusion. Through the Quality Assessment/Performance Improvement program, hospital leadership: A. Assesses and monitors the use of restraint or seclusion... .

A request was made to review the documentation for the assessment and monitoring for the use of restraints or seclusion and none was provided.

Interview with EMP1 on September 28, 2018, at approximately 10:00 AM confirmed the above findings and revealed, "It's [the Assesses and monitoring the use of restraint or seclusion] not done."