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.

MAIN LINE HOSPITAL PAOLI 255 WEST LANCASTER AVENUE PAOLI, PA 19301 June 20, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, review of facility policies and procedures, documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure the Condition of Participation for Patient Rights by failing to protect and promote the rights of each patient by failing to ensure care was provided in a safe setting (A0144),by failing to provide nursing services based on acceptable standards of practice (0385), by failing to ensure compliance with policies and procedures (A0057, 0395), and by failing to assume responsibility to provide oversight and accountability (A0043).


Cross Reference:

482.13(c)(2)Standard: Patient Rights: Care in Safe Setting
482.23 Condition of Participation: Nursing Services
482.23(b)(3) Standard RN Supervisor Of Nursing Care
482.12 (b) Chief Executive Officer
482.12 Condition of Participation: Governing Body
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, review of facility policy and interview with staff (EMP), it was determined the facility failed to identify and resolve unsafe practices for patients receiving telemetry monitoring for the following Nursing Units: 3A, 3Main, 4A, PCU (Progressive Care Unit), FCMU (Family Centered Maternity Unit).

Findings include:

Review of facility policy "Patient Rights, Complaints and Grievances" last reviewed January 2017 revealed "... . The governing body of Main Line Health hospitals has established Patient Rights and Responsibilities and a mechanism for the prompt resolution of complaints and grievances made to the hospital by a patient or the patient's representative. ..Care delivery-You have the right to: Expect emergency procedures to be implemented without unnecessary delay. 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."

Review of facility policy "Cardiac Monitoring Communication (MLH)" last reviewed March 2013, revealed "This policy applicable to: BMH, LMC, and PH (Paoli Hospital). The purpose of this policy is to provide Guidelines for equipment use and communication between Cardiac Monitoring Room staff and Care providers facilitating collaboration of critical alarm responsiveness. Performed by: RN, LPN, Monitor Tech, PCT, Unit Secretary (as appropriate to job role). Equipment-Hill-Room Locator system, Nurse Phones, Unit Phone (LMC), Telemetry Box Transmitters, Universal Alert. Methods of Communication: To be utilized in the following order as appropriate: 1. Hill-Rom or Nurse Phone 2. Unit Phone (LMC) 3. Universal Alert. Escalation of Communication: To be made from Monitor Tech to Unit staff in the following order as appropriate: 1. PCT 2. RN/LPN 3. Charge Nurse/Clinical Coordinator 4. Manager/Supervisor. Hill-Rom Locator System: All staff will be assigned a Hill-Rom locator that is to be worn at all times. Monitor Tech will verify locator presence of each caregiver at start of shift and contact unit of staff absence...Communication will be made to care for patients in a collaborative manner by providing open and timely communication between monitoring staff and unit staff regarding patient cardiac activity. Communication will be made to the appropriate discipline as outlined and then elevated to the next level as indicated. PCT(patient care technician) (all equipment concerns), Nurse (alarms, rhythm changes), Unit Secretary (unanswered calls to the nurse), Manager/Supervisor (unanswered calls or concerns). Hill-Rom or Nurse Phone will be the first line of communication between the Cardiac Monitoring Room and the nursing units. When staff are notified by monitor room to address a concern the staff will address the need immediately and or delegate another staff member to address the concern on their behalf. Communication to be documented on Monitor Tech report sheet/communication log. Nurse Phone-Oncoming RN will obtain phone at start of shift and change battery which will be located at the central station. Wipe phone cover with Sani wipe. Document phone extension on patient assignment sheet. Unit clerk will fax assignment sheet completed with phone extensions to the Central Monitor Room. RN will carry phone at all times to provide availability and ensure effective communication between the Cardiac Monitor Room and RN. The nurse will hand off the phone when leaving the unit to convening caregiver."

1. Observation on June 18, 2018, at 1:15PM in the hospital conference room revealed EMP3 with a facility issued phone. Further observation revealed EMP3 attempting to use the phone to contact the monitor technicians in the telemetry monitor room without success. Continued observation revealed the battery pack of the phone had become dislodged and EMP3 was struggling to position the phone's battery pack back into the battery compartment of the phone. Further observation revealed EMP3 placing the battery into the battery pack compartment of the phone and reapplying the adhesive tape to the phone to hold the battery pack in the battery compartment.

An interview conducted on June 18, 2018, at 1:30PM with EMP3 confirmed the phone was a facility issued phone to be used to support patient care. EMP3 stated "The battery pack of the phone falls out all the time. The staff miss so many calls with these phones however we are required to carry the phones to support the delivery of patient care and accessibility during our shift. EMP3 further stated that if an incoming call is missed there is no voice messaging to retrieve the missed call. EMP3 also stated that missed calls go to the nursing stations but after 7:30PM the nursing units do not have a unit secretary and the calls are missed if a nurse or PCT is not sitting at the nurse's station to respond."

2. Observation on June 18, 2018, at 1:30PM in the hospital conference room with EMP4 revealed EMP4 had a facility issued phone. Observation of EMP4's phone revealed rubber bands tied around the phone. Further observation revealed EMP4 was unable to use the phone to make a telephone call from the conference room and elected to use the land line phone to contact the monitor technicians in the monitor room.

An interview conducted on June 18, 2018, at 1:45 PM with EMP4 confirmed the reception was poor in areas of the hospital including the telemetry units as to the reason why a phone call could not be made from the hospital conference room. EMP4 further stated "In order to keep the phone powered up and receive calls I have to secure the battery pack with rubber bands because the battery pack keeps falling out. EMP4 also stated "Frequently the phone will lose all battery power which makes it difficult to communicate in a timely manner. Sometimes we cannot not make or receive calls. This is not a piece of equipment you can depend on to support delivering patient care. The facility requires nursing staff to carry these phones as well as many of the PCTs. The phone numbers are communicated to the monitor technicians to ensure our accessibility to resolve patient issues including patient telemetry problems or emergencies. There are times when the phone does not work, however the staff may not realize that until he or she does not receive any calls for the entire shift."

An interview conducted on June 18, 2018, at 8:45 PM with EMP11, EMP15 and EMP16 confirmed the facility requires licensed nurses to be assigned a facility issued phone. Further interview confirmed PCT's are not always assigned a phone. EMP16 confirmed that telemetry services are provided to patients on the following units: 3A, 3 Main, 4A, PCU and FCMU nursing units and the nursing staff delivering telemetry services are issued these same facility phones to communicate with the monitor technicians in the monitor room.

An interview conducted on June 19, 2018, at 9:59 AM with EMP18 revealed " There are many dead reception areas on the units where the phones do not work. There is a consistent pattern to the phones not working on many of the units and in areas of the hospital. Poor Reception and dead space is a common theme heard from all nursing staff regarding these phones There are times when the phones automatically shut down. When it is in your pocket or scrub jacket you would not know that the phone is off until you look at it."

An interview conducted on June 20, 2018, at 9:30PM with EMP11 revealed "The hospital administration has reviewed reception concerns regarding the facility issued phones staff are required to carry and found there to be no problems with reception."



Cross Reference:
482.12 - Condition - Governing Body
482.13 - Condition - Patient Rights
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of facility policies and procedures, documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure Nursing Services provided safe and effective patient care by failing to ensure nursing support staff was supervised (A0395 ); failed to ensure compliance with the Patient Rights: care in a safe setting (A0144); failed to ensure compliance with policies and procedures (A0057)


Cross Reference:
482.23 (b)(3) Standard Nursing Services: RN Supervision of Nursing Care
482.13 (c)(2) Standard Patient Rights: Care in Safe Setting
482.12(b) Chief Executive Officer
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on observation. review of facility policy, documents, medical record (MR), and interview with staff (EMP), it was determined that the Registered Nurse failed to supervise nursing support staff to ensure a safe and effective delivery of patient care.

Findings include:

Review of facility policy "Patient Rights, Complaints and Grievances" last reviewed January 2017 revealed "... . The governing body of Main Line Health hospitals has established Patient Rights and Responsibilities and a mechanism for the prompt resolution of complaints and grievances made to the hospital by a patient or the patient's representative. Patients treated in the hospital outpatient service shall be afforded the same rights granted to patients otherwise treated by the hospital...Care delivery-You have the right to: Expect emergency procedures to be implemented without unnecessary delay. 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."

Review of facility policy "Cardiac Monitoring Communication (MLH) " last revised November 16, 2016, "Hill-Rom Locator System. All staff will be assigned a Hill-Rom locator that is to be worn at all times. Monitor Tech will verify locator presence of each caregiver at start of shift and contact unit of staff absence."

A review of facility documents "Nursing Assignment" for Nursing Units: 3A, 3Main, 4A, 4B. PCU dated April 4, 2018 to June 8, 2018, revealed a unit designate form by shift used to track and confirm staff compliance with wearing a locator at the start of each shift. The attestation "ok" is scribed on the form next to the staff member's name. Further review revealed inconsistency by the monitor technicians for completing this form daily by shift.

An interview conducted on June 18, 2018, at 5:30PM with EMP3 and EMP4 confirmed that it is a requirement upon hire that staff is assigned a locator with a locator number that allows the staff to be located within the hospital. The location of the staff can be verified through the computer system. Further interview revealed that the locator automatically responds to the call light when the staff enters the room of the patient requesting assistance by turning the light green versus the initial red. In addition, EMP3 stated "We are also able to see the time and the specific staff that entered into a patient's room and the number of times entered."

An interview conducted on June 18, 2018, at 10:30AM with EMP3 and EMP4 confirmed that each employee is assigned a Hill Rom locator (aka-EGG). EMP4 also stated it was confirmed by administration and management staff that on May 28, 2018, EMP7 was caring for MR1 but was not wearing a locator for the entire scheduled shift. Further interview with EMP4 revealed EMP7 was not educated or counseled for noncompliance with the facility's policy.

An interview conducted on June 20, at 9:50PM with EMP11 and EMP12 revealed "There is no rounding requirement at this facility. Having the staff put a check in a check box in the medical record that he or she entered the patient's room does not support purposeful activity with patients. We engage our staff to do Purposeful Rounding which is reflected positively in our patient satisfaction scores." A policy was requested for "Purposeful Rounding" but the facility was unable to produce the document.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observations, review of facility policies and procedures, documents, medical records (MR) and interview with staff (EMP), it was determined the Governing Body failed to assume responsibility to provide oversight and accountability by failing to ensure compliance with policies and procedures (A0057, A0395), failed to ensure compliance with the Patient Rights Condition of Participation (A0115), failed to enure a safe environment for telemetry monitored patients and response to telemetry emergencies (A0385), failed to ensure a safe care environment was provided on the telemetry units resulting in an Immediate Jeopardy (A0007), and failed to ensure nursing services was evaluated and maintained and support staff was supervised (A0395).

Review of facility document "Hospital Plan of Care" last reviewed August 2017 revealed " The Hospital Plan of Care is a dynamic process, and is reviewed and/or revised annually. The Senior Management Team, in conjunction with the Main Line Health Board of Governors and Medical Staffs, are responsible for the ongoing monitoring and evaluation of the clinical, financial and organizational performance of each Hospital and for implementing changes as necessary to improve performance."

Findings include:




Cross reference:

482.12(b)-Standard: Chief Executive Officer
482.13-Condition of Participation: Patient Rights
482.13:Standard Patient Rights: Care in Safe Setting
482.23:Condition of Participation Nursing Services
482.23(b)(3): Standard RN Supervisior of Nursing Care
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on review of Governing Body Bylaws,documents, facility policies, medical records (MR) and interviews with staff (EMP), it was determined that the Chief Executive Officer (CEO) failed to ensure implementation of facility policies established by the hospital and the Board; for the management of patients receiving telemetry monitoring and failed to ensure telemetry alarm emergencies for these same patients were addressed in a timely manner for one of one medical record reviewed (MR1).

Findings include:

Review of the facility's "Amended and Restated Main Line Hospital Inc. Bylaws" dated June 7, 2018, revealed "... . Article V. ... Section 5.4 Chief Executive Officer. ... The Chief Executive Officer (CEO) shall inform the Corporation's Board of matters relating to the affairs of the Corporation. In exercising general management of the business of the Corporation, the CEO's duties shall include, but not be limited to, providing for compliance with applicable law and regulations; carrying out policies established by the Member and the Board and advising on the formation of such policies; collaborating with organizational leaders in developing and revising policies and procedures, submitting to the Board a plan of organization for the conduct of the Corporation's operation; preparing and annual budget showing the expected revenue and expenditures as request by the Board or its Executive Committee, developing and administer personnel policies and practices of the Corporation."

Review of facility policy "Cardiac Monitoring Communication (MLH)" last reviewed March 2013, revealed "This policy applicable to: BMH, LMC, and PH (Paoli Hospital). The purpose of this policy is to provide Guidelines for equipment use and communication between Cardiac Monitoring Room staff and Care providers facilitating collaboration of critical alarm responsiveness. Performed by: RN, LPN, Monitor Tech, PCT, Unit Secretary (as appropriate to job role). Equipment-Hill-Room Locator system, Nurse Phones, Unit Phone (LMC), Telemetry Box Transmitters, Universal Alert. Methods of Communication: To be utilized in the following order as appropriate: 1. Hill-Rom or Nurse Phone 2. Unit Phone (LMC) 3. Universal Alert. Escalation of Communication: To be made from Monitor Tech to Unit staff in the following order as appropriate: 1. PCT 2. RN/LPN 3. Charge Nurse/Clinical Coordinator 4. Manager/Supervisor. Hill-Rom Locator System: All staff will be assigned a Hill-Rom locator that is to be worn at all times. Monitor Tech will verify locator presence of each caregiver at start of shift and contact unit of staff absence...Communication will be made to care for patients in a collaborative manner by providing open and timely communication between monitoring staff and unit staff regarding patient cardiac activity. Communication will be made to the appropriate discipline as outlined and then elevated to the next level as indicated. PCT-patient care technician (all equipment concerns), Nurse (alarms, rhythm changes), Unit Secretary (unanswered calls to the nurse), Manager/Supervisor (unanswered calls or concerns). Hill-Rom or Nurse Phone will be the first line of communication between the Cardiac Monitoring Room and the nursing units. When staff are notified by monitor room to address a concern the staff will address the need immediately and or delegate another staff member to address the concern on their behalf. Communication to be documented on Monitor Technician Report Sheet/Communication log."

1. Review of MR1 "Nursing Note" dated May 28, 2018, at 9:11 PM written by EMP 8 revealed "Entered pt's room to administer meds. Pt unresponsive w/cyanotic oral mucosa. No carotid pulse palpable. No respirations. Briefly looked at rhythm and could see AV paced rhythm/no alarms. Code blue called. See code blue documentation."

Review of facility document "Monitor Technician Report Sheet/Communication Log" revealed "05/28/18, 3-11, "...Try to call multiple time with Artifact, No answer, 9:12 PM Code Blue Call, The Strips all artifact...Pt pass away. EMP17."

Review of MR1 "Code Documentation Event and Staff Data:" May 28, 2018, at 9:12 PM to 9:26PM revealed "9:12PM Code Start by EMP8, 9:13PM Cardiac Rhythm: Asystole. ... . Code End 9:26PM."

An interview conducted on June 18, 2018, at 9:19AM with EMP1 and EMP3 confirmed that EMP17 was the assigned monitor technician for MR1 on May 28, 2018 incident. EMP3 stated that during an interview with EMP17, it was communicated by EMP17 that the telemetry monitor for MR1 was displaying artifact and alarming and several attempts were made to reach a patient care technician without success to troubleshoot the alarm. EMP1 and EMP3 also stated that EMP 17 self disclosed that the telemetry alarm had been repeatedly silenced during the attempts to contact a patient care technician.

An interview conducted on June 18, 2018, at 9:30AM with EMP1, EMP2, EMP15 and EMP16 revealed that the Hospital's administration and designated staff met on June 6, 2018, to review the incident and it was determined the incident occurred due to EMP17's failure to follow the facility's policies and procedures. In addition, EMP16 stated "The hospital's administration staff decided it was not necessary to revise or create new policies and procedures or to change the telemetry units workflow as to how the monitor technicians communicate with nursing staff. EMP16 further stated that this was a single incident which does not reflect the quality of care delivered to the patients by the hospital.

An interview conducted on June 18, 2018, at 10:00PM with EMP11 and EMP12 confirmed that the hospital's administration perceived the May 28, 2018, for MR1 as an incident due to the failure of EMP17 to follow the facility's policy. EMP11 confirmed that there was no need to change the telemetry staff's communication workflow.

2. Review of facility policy "Rapid Response Team (RRT) and Condition H" last revised October 2017, revealed "A Rapid Response Team (RRT) will be readily available at all times to respond and provide bedside assessment for hospital patients that require immediate medical attention within the Main Line Health acute care hospitals. The team will function as a stat resource team for patients meeting the criteria for initiating the RRT. Purpose: To assure a mechanism exists to promptly assess, define and initiate a care plan whenever a patient requires immediate medical evaluation. Criteria for Initiating the Rapid Respond Team, Criteria including, but not limited to: Staff member is concerned about the patient...Acute change in mental status (delirium, confusion, etc...). Failure to respond to treatment for an acute problem/symptom. NOTE: Patients only need to meet one criterion to initiate the RRT."

Review of facility document "Monitor Technician Report Sheet/Communication Log" revealed "05/28/18, 3-11, "...Try to call multiple time with Artifact, No answer, 9:12 PM Code Blue Call, The Strips all artifact...Pt pass away. EMP17."

An interview conducted on June 18, 2018, at 2:00PM with EMP15 revealed "This may have been a incident that the RRT could have responded to if it was initiated by the nurse. Having a monitor tech initiate a RRT response is not within the scope of their responsibility."

An interview conducted on June 18, 2018, at 5:58 PM with EMP19 revealed "Monitor Technicians do not call a RRT, they should be calling the nurse and if unable to reach the nurse, call the charge nurse and or the nursing supervisor."

An interview conducted on June 19, 2018, at 9:30AM with EMP18 revealed "Monitor Technicians do not call RRT's as it would be perceived as an insult to a nursing supervisor or a charge nurse as to why he/she was not contacted before a RRT was called. However, it would be helpful if the nursing staff would answer their phones."