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LEHIGH VALLEY HOSPITAL 1200 SOUTH CEDAR CREST BOULEVARD ALLENTOWN, PA 18103 July 17, 2018
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy and procedures, review of medical records (MR), and interviews with staff (EMP), it was determined the facility failed to ensure accurate medical record documentation for follow up discharge instructions in three of four Emergency Department (ED) medical records reviewed (MR1, MR3, MR4).

Findings include:

Review on July 17, 2018, of facility policy "Post Exposure Prophylaxis for [DIAGNOSES REDACTED] - Infection Control," approved May 21, 2018, revealed, " ... IV. Procedure D. 2. Not previously vaccinated: a. Administer 20 IU/kg body weight [DIAGNOSES REDACTED] HRIG. (This formula is applicable to all age groups, including children ... b. Human diploid cell vaccine (HDCV) or purified check embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area), one each on days 0, 3, 7, and 14. (Day 0 is the day the first dose of vaccine is administered.)"

Review on July 17, 2018, of ED Provider "Follow Up" documentation in MR1, MR3 and MR4 revealed, " ... Follow-up ... Go in 2 days ... ". Review of the "After Visit Summary (Discharge Instructions)" for MR1, MR3 and MR4 revealed " ... Follow up Care ... You will need another vaccination at 3 days, 7 days and 14 days from your first vaccine".

Interviews on July 17, 2018, at 1:45 PM with EMP4 and EMP5 confirmed the ED provider follow up documentation for treatment in MR1, MR3 and MR4 was 2 days and the "After Visit Summary" instructions were to follow up for treatment at 3 days, 7 days and 14 days.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on review of facility policy and procedures, review of medical records (MR), and interviews with staff (EMP), it was determined the facility failed to ensure Emergency Services were provided per facility policy in four of four medical records reviewed (MR1, MR2, MR3, MR4).

Findings include:

Review on July 17, 2018, of facility policy " Post Exposure Prophylaxis for Rabies - Infection Control," approved May 21, 2018, revealed " ... IV. Procedure D. 2. Not previously vaccinated: a. Administer 20 IU/kg body weight rabies HRIG. (This formula is applicable to all age groups, including children ... b. Human diploid cell vaccine (HDCV) or purified check embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area), one each on days 0, 3, 7, and 14. (Day 0 is the day the first dose of vaccine is administered.)"

Review on July 17, 2018, of MR1, MR2, MR3 and MR4 revealed these patients presented to the facility's Emergency Department for treatment of possible exposure to rabies. Further review of MR1, MR2, MR3 and MR4 revealed no documentation the Human diploid cell vaccine (HDCV) or purified check embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area) was given on Day 0.

Interviews on July 17, 2018, at 1:45 PM with EMP4 and EMP5 confirmed there was no documented evidence in MR1, MR2, MR3 and MR4 of the Human diploid cell vaccine (HDCV) or purified check embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area) was given on Day 0.