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||Feb. 14, 2019|
|VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION||Tag No: A0168|
|Based on tour of facility, review of facility policy, 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 four of four medical records reviewed (MR20, MR21, MR22, and MR23).
Review of facility policy Restraint and Seclusion, last revised September 2018, revealed, " ... Restraint ... The following are examples of devices that are available for use as restraints, when alternatives are not effective: ... G. Side rails (unless an exception applies as described in ' exclusion to restraint ' ) ... Exclusions to Restraint ... F. Side Rails: use of full side rails are not restraints if used as a prudent safety measure in the following situations: 1. Patients who are sedated pre or post operation or procedure. 2. Patients who experience involuntary movements that affect their safety (seizure precautions, Huntington ' s disease, for example.) 3. Patients placed on surfaces in high positions or placed on therapeutic surfaces that could increase the risk for fall (e.g. roto prone beds, critical care beds whose standard height is greater than a regular medical surgical bed.) 4. Patients placed on stretchers. ... "
Tour of Unit 7C on February 14, 2019, at 12:30 pm revealed six patients with four side rails in the up position while the patients were in bed. Review of MR18 and MR19 revealed patients were on seizure precautions and met the facilities exclusions to restraint criteria. Review of MR20, MR21, MR22, and MR23 revealed no physician order or exclusion to restraint criteria for four side rails.
Interview with EMP5 on February 14, 2019, at 12:45 confirmed the above did not have physician orders to use four siderails.
|VIOLATION: MEDICAL STAFF BYLAWS||Tag No: A0353|
|Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the medical staff bylaws where enforced for three of three medical record reviewed (MR7, MR8, and MR9).
Review of facility documentation "Allegheny General Hospital Medical Staff Rules And Regulations" dated September 19, 2016, revealed "2. The use of the terms "renew" "repeat", and "continue" with respect to previous orders is not acceptable."
Review of facility policy "Medication Ordering" last revised June 2018, revealed "B. Resume/Renew/Reorder 1. An order to "Resume" or "Renew" previous orders is not an acceptable order. An AP (advanced practitioner) will need to rewrite all orders, prior to the dispensing of any medications."
Review of MR7 on February 14, 2019, revealed a physician order dated February 12, 2019 "resume meds held for procedure after 24 hours."
Review of MR8 on February 14, 2019, revealed a physician order dated January 30, 2019 "resume mds held for procedure after 24 hours."
Review of MR9 on February 14, 2019, revealed a physician order dated January 04, 2019 "resume meds held for procedure after 24 hours."
Interview with EMP2 on February 14, 2019 at 12:48 PM confirmed the above findings.