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 GENERAL HOSPITAL 320 EAST NORTH AVENUE PITTSBURGH, PA 15212 June 1, 2018
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on a review of facility documentation, medical records (MR) and staff interviews (EMP), it was determined the facility failed to conduct a formal complaint/grievance investigation for one medical record reviewed (MR1).

Findings include:

1) Review of facility policy "Patient Complaints, Grievances and Compliments," Policy Scope: This policy applies to the (facility) entities and individuals identified in the applicability section below. This policy and procedure applies to all provider entities within the ...Network, including inpatients and outpatients, and including off-site provider based locations and physician offices ..."

2) Review of MR1 Telephone Encounter Note dated 3/30/18 revealed " ...EMP7 Supportive Care Navigation Note Call placed to (family member) for follow-up post-acute supportive care. (Family member) ...States ...very upset with discharge as there " were no d/c (discharge) instructions sent with the patient to (Skilled Nursing Facility-SNF) and was not notified MR1 had MRSA ...will be placing a complaint with (facility). I apologized and offered support in any way that I can assist ...reported incident to manager EMP8 ... "

During interview on May 31, 2018 at approximately 9:00AM both EMP7 and EMP8 confirmed being aware of MR1's family member's concerns and desire to file a complaint and further confirmed that no complaint investigation was conducted.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on review of facility documentation, medical records(MR), and staff interview (EMP), revealed the facility failed to ensure nursing care policies and procedures consistent with professionally recognized standards of nursing practice were followed for one of three medical records reviewed (MR14).


Findings include:


Review of facility guidelines for Prevention of Medical Device-Related Pressure Injuries revealed, "Remove or move removable devices to assess skin at least daily."

Review of MR14 Daily Care Plan revealed, Assess skin integrity/risk for skin breakdown and implement plan of care and interventions per policy. Further review revealed no assessment of C- Collar on May 5 and May 6, 2018.

Interview with EMP2 on June 1, 2018, at approximately 1:00 pm confirmed the above findings.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on a review of facility documentation, medical records (MR), and staff interview (EMP), it was determined that facility failed to follow a physician order and their MRSA Surveillance policy by not completing MRSA nasal swab for one medical record reviewed (MR1).

Findings include.
Review of facility policy "Screening and Culturing for Methicillin Resistant Staphylococcus Aureus (MRSA) in High Risk and Nursing Home Patients" last revised 02/2018 revealed "Policy Statement: Pennsylvania Act 52 requires hospitals to have processes in place for active culture surveillance as well as identification of patient known to be colonized and/or infected with MRSA or other multi-drug resistant organism (MDRO). The [facility] complies with Pennsylvania Act 52 requirements by screening nursing home residents admitted to any area of our acute care hospital for MRSA .... "

Review of MR1 Default Flowsheet Data dated 03/13/18 at 1743 MRSA Screening revealed "...Is the patient from nursing home? Yes, MRSA Surveillance Screen needed."

Review of MR1 physician order dated 03/19/18 at 1420 revealed " MRSA Surveillance Screen (Order 2093) ..."
During interview on May 31, 2018 at approximately 1:00PM EMP1 confirmed MR1 required an MRSA nasal swab screening on admission from a nursing home but the test was never completed.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
Based on review of facility documentation, medical records (MR), and staff interviews (EMP), it was determined the facility failed to transfer patients to another facility with clinical records of sufficient content to insure continuity of care for 11 of 11 medical records reviewed (MR1-MR11).

Findings include:

Review of facility policy and procedure "Admission, Discharge, Reservation, and Transfer of Patients" reviewed August 2018, revealed "The Discharge Progress Note/Discharge Instructions will be provided to the patient/family and sent by the electronic health record to the patient's next care provider. ... 19. Patients shall not be discharged without a written discharge instruction sheet."

Review of facility policy "Patient Assessment/Reassessment" last approved March 2018 revealed"...Discharge...Timely and accurate information shall be provided to the patient/family/caregiver or transfer facility...to ensure the patient's transition between care settings is smooth..."

Review of facility policy and procedure "General Discharge Instructions" reviewed October 2017, revealed " 11. Provide patient/significant other with printed copy of the after visit summary (AVS). 12. If patient is being discharged to a network extended care facility, a copy of the after visit summary will be sent with the patient. When the patient is not going to a network extended care facility, a copy of the patient chart and the after visit summary (AVS) will be sent with the patient. "

1) Review of MR1 revealed the patient was transferred via ambulance to an outside facility on March 27, 2018. Further review of MR1 revealed no documentation in MR1 that confirmed a copy of the patient's chart was sent with the ambulance service or clinical records were faxed to the receiving facility.

During interview on May 31, 2018 at approximately 12:00PM, EMP9 confirmed the above findings.

2.. Review of MR2, MR3, MR4, and MR5 revealed the patient's were transferred to a outside facility. Further review revealed no documentation a copy of the patient chart and the after visit summary was sent with the patient as per above policy.

Interview with EMP5 on May 31, 2018, at approximately 11:50 AM confirmed the above findings and revealed "There is no documentation."

Interview with EMP4 on May 31, 2018, at approximately 12:05 AM confirmed the above findings and revealed "Other than the report being called, it [medical record] doesn't say paperwork was sent."

3. Review of MR6, MR7, MR8, MR9, MR10, and MR11 revealed the patient's were transferred to a outside facility. Further review revealed no documentation a copy of the patient chart was sent with the patient as per above policy.

Interview with EMP2 on June 1, 2018, at approximately 10:00 AM confirmed the above findings and revealed "There is no solid place to document the medical record went with the patient."