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.

Based on review of facility documentation, medical records (MR), and staff (EMP) interview, it was determined the facility failed to ensure that a copy of the hospital's Patient's Bill of Rights was given to each patient or responsible party upon admission or as soon after admission as feasible for 11 of 11 medical records reviewed (MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, and MR12.)

Findings include:

On May 25, 2021, a review of the following policy "Patient Rights and Responsibilities," revised date 5/2021, revealed "Scope: This policy applies to the AHN entities and individuals outlined in the policy applicability section below. Statement: Allegheny Health Network (AHN) wants patients, and their family members (as defined by the patient) or guardians, to know their rights under federal and Pennsylvania state law as soon as possible during a hospital stay. ... Administration: ... B. Copies of patient's right and responsibilities are displayed in the inpatient and outpatient registration areas of the hospitals and freestanding outpatient sites. All inpatients will receive a copy of their rights and responsibilities at the time of registration or admission. Patient rights and responsibility brochures will be visible and available to patients at each visit."

On May 25, 2021, a review of the brochure given to patients at the time of admission revealed "Your hospital stay-information for you and your visitors ... Understanding your rights and responsibilities ... you have the right to: Treatment without discrimination. Safe, respectful, and dignified care at all times. Instructions and information you can understand. Participate in decisions about your care. Care that supports you and your family. Access to your billing and medical records. ... You can help us provide quality care by doing your part. This includes: Following hospital rules and regulations. Respecting our clinical staff and other employees, as well as other patients, families and visitors. Providing accurate and complete information about your illness or treatment. Working actively with your clinical staff to implement your treatment plan. For a complete list of your rights and responsibilities as a patient, please visit [website provided]. ...

On May 25, 2021, record reviews were completed for MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, and MR12. These records indicated that the patients received the admission guide. The admission guide did not include an inclusive list of patient's rights and responsibilities.

During an interview on May 25, 2021, at 12:10 PM, EMP1 confirmed inpatients are not given an inclusive list of their rights and responsibilities at the time of admission. Further interview confirmed that patients are given the above brochure that lists some of the most common rights and responsibilities.
Based on review of facility policy, facility tour, and interview with staff (EMP), it was determined the facility failed to ensure a hospital employee followed the policy for hand hygeine on the nursing unit.

Findings include:

Review of the facility policy "Hand Hygiene," last revised December 2017, revealed "Policy Scope: This policy applies to the AHN entities and individuals outlined in the policy applicability below. Policy Statement: This policy states the expected hand hygiene practices for physicians, healthcare workers, licensed independent practitioners, volunteers, students, observers, sales representatives, or contracted services personnel who interact with patients, families or equipment at any Allegheny Health Network facility. ... Guideline and/Procedures: ... B. Key Principles 1. Hand hygiene must be performed: a. Before entering and when exiting patient rooms. ..."

On May 25, 2021 at 10:00 am, observation of Intensive Care Unit (ICU) unit revealed EMP7 exit room 626, enter room 627, exit room 627, and enter room 631 without performing hand hygiene.

Interview with EMP2 on May 25, 2021 at 10:05 am, confirmed the above. EMP2 stated they addressed the matter with EMP7 and EMP7's manager.