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.

ST LUKE'S HOSPITAL - ANDERSON CAMPUS 1872 ST LUKE'S BLVD EASTON, PA 18045 July 20, 2018
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure the patient's plan of care was modified for the use of restraints in two of three medical records reviewed (MR8, MR9).
Findings include:
Review on July 20, 2018, of facility policy "Restraint Use (D-32), revised May 2018, revealed, " ... III. Restraint for Non-Violent/Non Self-Destructive Behaviors ... F. Documentation ... k. The patient plan of care will be updated when restraints are applied or removed."
Review on July 20, 2018, of MR8 revealed the patients was placed in restraints on July 4, 2018. Further review of MR8 revealed no documentation the Plan of Care was modified or updated for use of restraints.
Review on July 20, 2018, of MR9 revealed the patient was placed in restraints on June 22, 2018. Further review of MR9 revealed no documentation the Plan of Care was modified or updated for the use of restraints.
Interview with EMP1 on July 20, 2018, at 12:45 PM confirmed there was no documented evidence the Plan of Care was modified or updated for the use of restraints in MR8 and MR9.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on review of policies and procedures, facility documents, and interviews with staff (EMP), it was determined the facility failed to ensure a syringe was used on only one patient.

Findings include:

Review on July 19, 2018, of the facility's "Infection Control Plan Calendar Year 2018", revealed "The department refers to the following standards as guidelines: APIC (The Association for Professionals in Infection Control) Guidelines for Infection Control and Epidemiology. Guidelines and regulations from the CDC ..."

Review on July 19, 2018, of the Centers for Disease Control and Prevention [CDC]'s "Protect Patients Against Preventable Harm from Improper Use of Single-Dose/Single-Use Vials", dated August 30, 2016, revealed "Basic Safe Injection Practice Messages A. CDC evidence-based guidelines define safe injection practices under Standard Precautions. These include one-time use of needles and syringes ... B. Unsafe injection practices include, but are not limited to, reuse of syringes for multiple patients ..."

Review on July 19, 2018, of a facility document, dated June 5, 2018, revealed "event: [MR2] Date of Event: 5/29/2018 ... Description of Event: Syringe of propofol used on one patient was inadvertently used on another patient."

Review on July 19, 2018, of "Strategies for Improvement", dated June 5, 2018, for event # revealed "1. Syringes are single use ... "

Review of a facility document, dated June 7, 2018 at 12:40 PM, revealed "we had a medication error at Anderson ... In the GI [gastrointestinal] lab there, we had one [Anesthesia provider] who never refills a Propofol syringe, and one who does. The one relieving assumed that the full propofol syringe must be clean since [Anesthesia provider] never refills. [Anesthesia provider] was wrong, it was used and refilled."

Interview with EMP2, on July 19, 2018, at 11:10 AM confirmed [CF2] was taking care of the GI patient. [CF2] used the syringe of Propofol on the patient [MR1]. [CF2]Refilled the syringe and put it on top of the anesthesia cart. [CF3] relieved [CF2] for a break. [CF2] gave [CF3] a report. [CF2] left but did not talk about the patient. Patient taken out of room when colonoscopy was completed. [CF3] thought because the syringe was full and clean, that it was clean and unused. [CF3] used the syringe on MR2. The syringe was labeled with the patient name in MR1. [CF2] came back from break and asked [CF3] if [CF3] used the syringe on patient in MR2 and [CF3] answered yes. [CF2] and [CF3] notified leadership syringe was used on two patients [MR1 and MR2]. EMP2 confirmed the propofol syringe was used on two patients MR1 and MR2.
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
Based on a review of facility policy, review of medical record (MR), and interview with staff (EMP), it was determined the facility failed to notify a family member or representative of patient's choice of his or her admission to the hospital for three of four medical records reviewed (MR20, MR21, and MR22).

Findings include:

Review on July 19, 2018, of policy "Rights and Responsibilities - Patients (#86)", dated August 2016, revealed "25. Patients have the right to have a family member or representative ... of their choice promptly notified of their admission to the hospital."

Review on July 19, 2018, of the "St Luke's Anderson Campus Patient Guide", dated March 2018, revealed on page six "Rights and Responsibilities ... Communication You have the right to: Have a family member, another person that you choose, ... notified when you are admitted to the hospital."

Review on July 19, 2018, of MR20, MR21, and MR22, revealed no documented evidence that patients' family members or representatives were notified of patients' admission to hospital.

Interview on July 19, 2018, at 2:55 PM, with EMP1, confirmed there was no documented evidence in MR20, MR21, and MR22, that the patients' family members or representatives were notified of the patients' admissions to the hospital.