HospitalInspections.org

The Physical Environment Condition was found to be out of compliance during a Life Safety Survey completed on December 13, 2018. Further details are outlined in that Division of Life Safety Survey Report.

Based on a review of medical records (MR), facility policies and staff interview (EMP), it was determined that the facility failed to ensure patients that are restrained are being monitored by a physician, other licensed practitioner or trained staff for five of five medical records reviewed (MR24, MR25, MR26, and MR27).


Findings include:


A review of the facility's "Clinical Services Policy & Procedures" reviewed 2/28/18, stated "Medical Record Documentation, ... Modification of the patient's treatment plan related to restraint use, patient's response and plan for reduction/elimination is included in the patient's medical record. Interdisciplinary Team Member documentation must: ... State observations/interventions/findings from periodic observations, to include: safety, comfort, mobility, skin integrity, food/hydration and toileting, to include removal of the restraints at least 10 minutes every 2 hours or more often (observations every two hours for medical restraints and every 15 minutes for behavioral restraints) ... . "


A review of MR24 on January 3, 2019, revealed restraint orders initiated for bilateral mitts on 12/17/18, at 08:00 AM. Further review of MR24 revealed restraint documentation of observations began at 08:00 AM, stopped at 12:00 PM, and resumed at 5:00 PM. There was no documentation in the medical record to indicate the patient was being observed, as per policy.


A review of MR25 on January 3, 2019, revealed restraint orders initiated for bilateral mitts on 10/19/18, at 08:00 AM. Further review of MR25 revealed restraint documentation of observations began at 8:00 AM, stopped at 6:00 PM, and resumed at 10:00 PM. There was no documentation in the medical record to indicate the patient was being observed, as per policy.



Additional review of MR25 on January 3, 2019, revealed restraint orders initiated for bilateral mitts on 10/22/18, at 08:00 AM. The review of MR25 also revealed restraint documentation of observations began at 8:00 AM, stopped at 12:00 PM, and resumed at 7:00 PM. There was no documentation in the medical record to indicate the patient was being observed, as per policy.


A review of MR26 on January 3, 2019, revealed restraint orders initiated on 11/12/18, at 8:00 AM. Further review of MR26 revealed restraint documentation observations began at 8:00 AM, observations stopped at 12:00 PM, and resumed at 7:00 PM. There was no documentation in the medical record to indicate the patient was being observed, as per policy.



A review of MR27 on January 3, 2019, revealed restraint orders initiated for bilateral mitts on 11/19/18, at 8:00 AM. Further review of MR27 revealed restraint documentation observations stopped at 12:00 PM, and resumed at 6:00 PM. There was no documentation in the medical record to indicate the patient was being observed, as per policy.



During interview with EMP3 on January 3, 2019 EMP3 confirmed the above findings.

Based on a review of facility documentation, medical records (MR) and employee interview (EMP), it was determined the facility failed to ensure the evaluation of the nursing care for each patient for three of five medical records reviewed (MR14, MR15, and MR18).

Findings include:

Review of the facility policy and protocol "Pain Management Assessment and Intervention Protocol," last revised April 01, 2018, revealed "Pain is what the experiencing patient says it is. The patient's self report is the single most reliable indicator of the existence and intensity of pain. ... E. Re-Assessment: i. Pain will be assessed prior to pain reduction interventions. ...iii. Pain will be reassessed 30-60 minutes following a pain reduction intervention."

Review of MR14 revealed that the patient received Oxycodone 5mg by mouth every 4 hours for moderate pain on November 5, 2018, at 1425, November 7, 2018, at 0200, November 9, 2018, at 0300, and November 19, 2018, at 1424. Further reviewof MR 14 revealed no documentation of a reassessment, as per facility policy.

Review of MR15 revealed that the patient received Oxycodone 15 mg by mouth every 3 hours for severe pain on November 26, 2018, at 1800 and 2230, November 28, 2018, at 0330 and 0630, and November 30, 2018, at 0900 and 1200. Further review of MR15 revealed no documentation of a reassessment, as per facility policy.

Review of MR18 revealed that the patient received Oxycodone HCL 5mg PT (parental tube) every 4 hours for pain on October 6, 2018, at 0045 and 1515, October 7, 2018, at 0615 and 1035, and October 8, 2018, at 0150, 2000, and 0000. Further review of MR 18 revealed no documentation of a reassessment, as per facility policy.

Interview with EMP3 on January 4, 2019, during the time of the medical records reviews, confirmed the above findings.

Based on a review of facility policies and staff interview (EMP), it was determined that the facility failed to ensure that medical order was complete for one of one medical records reviewed (MR23).

Findings include:

Review of the facility's "Clinical Services Policy and Procedure: Orders, Physician," last reviewed February 2018, stated " ... 1. A complete medication order consists of: ... C. Frequency of administration. ... 2. Medication name, dose and frequency must be written by LIP (licensed independent practitioner). ... ."

Review of MR23 revealed an order written: for Fentanyl 50 mg, IV, Versed 1mg IV, may repeat dosed as needed.

Interview with EMP3 January 4, 2019, EMP3 confirmed the above and acknowledged that the order lacked frequency parameters of administration.

Based on review of facility policy, medical records (MR), and staff interview (EMP), it was determined the facility failed to document a final diagnosis for all medical records for three of four medical records reviewed (MR7, MR9, and MR10).
Findings include:
Review of facility policy, "Physician Documentation Requirements," dated January 22, 2018, revealed, "... Discharge/Death Summary: Required for patient stays greater than 48 hours. Name of patient, date of admission and discharge, principal and secondary diagnoses, reason for LTCH (Long Term Care Hospital) hospitalization, significant findings/hospital course, procedures performed and treatment rendered, patients condition at discharge, specific instructions including: physical activity, diet and medications with dosage. For discharge summary documentation to be used for coding and DRG (Diagnostic Related Group) assignment, it should be on the chart within 7 days of discharge."
Review of MR7 on January 4, 2019 revealed the patient was discharged on September 28, 2018. Further review of MR7 revealed no final diagnosis was documented in the medical record.
Review of MR9 on January 4, 2019 revealed a discharge date of September 12, 2018. Further review of MR9 revealed no final diagnosis was documented in the medical record.
Review of MR10 on January 4, 2019 revealed a discharge date of October 2, 2018, with no final diagnosis documented in the medical record.
Interview with EMP7 on January 3, 2019, at approximately 12:30 pm, confirmed the above findings.

Based on review of facility policy and observation and employee interviews (EMP), it was determined the facility failed to ensure the condition of the physical plant was maintained in such a manner that the safety and well-being of patients are assured.

Findings include:

Review of the 2018 Guidelines for Design and Construction of Hospitals and Outpatient Facilities revealed, "Table 2.1-4 Hot Water Use - General Hospital ... Temperature (F) Clinical 105 - 120 degree ... The range represents the maximum and minimum allowable temperatures." Further review revealed "2.1-8.4.3.4 Ice-making equipment. Copper tubing shall be provided for supply connections to ice-making equipment."

Review of facility policy and procedure "Prevention & Control of Legionellosis Associated with Building Water System" dated October 29, 2018, revealed "I. Prevention ... C. Hot water delivered should be maintained at a minimum of 110 degree F(farenheit) at the outlet, preferably 120 degree F in the hospital setting, unless dictated by regulatory guidelines.

A request was made on January 3, 2019, to review water temperatures for patient showers and none was provided.

Interview with EMP5 on January 3, 2019, at approximately 10:45 AM, confirmed the above findings and that water temperatures are not checked.

During a tour on January 3, 2019, at approximately 10:30 AM observation of an ice machine in the patient nourishment room revealed stainless tubing and not copper tubing, as per the 2018 Guidelines for Design and Construction of Hospitals.

Interview with EMP5 on January 4, 2019, at approximately 9:30 AM confirmed the above findings.

Based on a review of facility documentation and staff interview (EMP), it was determined the facility's Infection Control Officer failed to implement the facility's Infection Control Plan regarding the inclusion of a community member in the facility's Infection Control Committee meetings.

Findings include:

Review of the facility's Infection Control Plan last revised October 2018 revealed "...Committee Structure...For hospitals in Pennsylvania additional members will include a community representative not affiliated with the hospital... ."

A review of facility Infectin Control Committee meetings dated January 17, 2018, April 18, 2018, July 31, 2018, and November 28, 2018, revealed no community members attended those respective meetings.

During and interview on January 3, 2019, at approximately 12:45 PM, EMP2 confirmed the above findings and revealed the facility did not have a community member who attended Infection Control meetings as of the last meeting conducted on November 28, 2018.