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Based on a review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to follow their adopted Patient Rights policy by failing to ensure the implementation of good management techniques, related to the consideration of effective use of the time for patients, in three of three medical records reviewed. (MR12-MR14)

Findings include:

"Rights and Responsibilities - Patient," last reviewed January 18, 2018, revealed "... The following are minimal provisions for the Patient's Bill of Rights: (1) A patient has the right to respectful care given by competent personnel ... (7) The patient has the right to good quality care and high professional standards that are continually maintained and reviewed...Care delivery: You have the right to ... 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...(16) The patient has the right to expect good management techniques to be implemented within the hospital considering effective use of the time of the patient and to avoid the personal discomfort of the patient ... ."

1. Surgical Reports dated August 1, 2019-November 14, 2019, were reviewed. It was noted that there were three instances associated with EMP9, related to delays and then subsequent surgical cancellations. Surveyor requested associated medical records for review.
2. Review of MR12, dated 8/6/19, revealed "... Surgical Documentation ... 8/6/2019 06:12 ... Arrival Date and Time: 8/6/2019 06:05 ... Reason for Visit: Outpatient Surgery ... 11:25 ... surgery cancelled due to dr. not here ... ."
Review of MR13 dated 8/12/19, revealed "... Arrival Date and Time: 8/12/2019 08:06 ... 11:20 ... surgery rescheduled ... ."
Review of MR14 dated 8/6/19, stated "... Arrival Date and Time: 8/6/2019 07:59 ... 11:30 ... surgery cancelled due to dr. not here ... ."
3. Interview with EMP10 on November 15, 2019, revealed "... EMP9 is just late all the time ... ."
4. Interview with EMP12 on November 15, 2019, revealed "... EMP9 is routinely late ... ."
Cross reference with:
482.51 (b) Operating Room Policies

Based on a review of facility documents and staff interviews (EMP), it was determined the facility failed to follow adopted policies related to process related to suspicion of an impaired employee, and failed to ensure that employees had a working knowledge of applicable policies.

Findings include:

Review of "Amended and Restated Bylaws of DuBois Regional Medical Center d/b/a Penn Highlands DuBois. A Pennsylvania Nonprofit Corporation", dated June 18, 2019, revealed "... Article VII Medical Staff Section 7.1 General. The Board shall appoint a medical staff operating in accordance with these Bylaws and those bylaws of the medical staff approved by the Board ... Section 7.5 Delegation to Medical Staff of Certain Responsibilities and Authorities ... Section 8.2 Delegation to Administration and to the Medical Staff ... (b) To the Medical Staff. The Board delegates to the medical staff and holds it accountable for conducting specific activities that contribute to the preservation and improvement of the quality and efficiency of patient care provided by the Corporation. These activities include ... (5) Management of clinical affairs, including enforcement of medical staff bylaws, rules and regulations, of clinical policies, initiation of disciplinary actions, surveillance over requirements for performance monitoring, and for the exercise of newly-acquired clinical privileges, and like clinically-oriented activities ... ."

Review of the "Penn Highlands Brookville; Clearfield; DuBois, Elk; Dubois Surgery Center; DuBois Endoscopy Center; Elk Surgery Center Medical Staff Bylaws", dated June 2019, was completed, and revealed "... Article II: Medical Staff Membership ... Responsibilities of Membership ... Each staff member must submit to any health evaluation to confirm the staff member's ability to practice safely the privileges that have been granted consistent with the provisions of the Physician Health Policy ... V: Departments and Clinical Services ... The Medical Staff at Penn Highlands DuBois ... shall be departmentalized and is organized into three departments: the Medical Department, the Ambulatory Department, and the Surgical Department ... Each department shall be responsible for the monitoring and evaluation of the quality of care and the professional performance of clinicians who are privileged through the medical staff at each Penn Highlands Healthcare Hospital. Each department shall have a chief with overall responsibility for the supervision and satisfactory discharge of the functions of the department ... ."
Review of the "Penn Highlands Healthcare Brookville; Clearfield; DuBois; Elk; DuBois Surgery Center; DuBois Endoscopy Center; Elk Surgery Center Appendix B Organization and Functions Section (Referenced in Medical Staff Bylaws), dated June 2019, revealed "... 1.3 Description of Medical Staff Functions. 1.3.1 Main Functions of Department (a) Each department chief, with input from the department members, shall recommend appointment and reappointment for members to the Credentials Committee ... (b) Each department shall systematically evaluate the effectiveness and efficiency of the patient care provided by physician members ... 1.3-2 Governance, Direction, Coordination, and Action ... (d) Clinical performance on the part of Staff members, including initiating investigations and initiating and pursuing corrective action, when warranted (MEC, President) ... 1.3-13 Responsibilities of Department Chiefs. A department chief will be elected by the members of the Medical Department for the Medical Department, and by the members of the Surgical Department for the Surgical Department and by members of the Ambulatory Department for the Ambulatory Department ... The responsibilities of the Medical, Surgical and Ambulatory Departments Chiefs will be as follows: (a) Be accountable to the MEC for all professional and administrative activities within the Department; (b) Be a member of the MEC giving guidance on the overall medical policies of the hospital and making specific recommendations regarding the department ... (d) Enforcement of the Hospital Bylaws and the Medical Staff Bylaws, Rules and Regulations within the department; (e) Be responsible for implementation within the department of actions taken by the MEC or the medical staff ... (g) Assure that the quality and appropriateness of patient care provided in the department are monitored and evaluated, and be responsive for implementing action following review and recommendations by the MSQC ... (i) Participate in every phase of administration of the department through cooperation with nursing services and hospital administration in matters affecting patient care ... 1.3-14 Responsibilities of the Medical Staff President ... (c) Enforce Medical Staff Bylaws, Medical Staff Rules and Regulations, and hospital policy ... ."
Review of the policy entitled "Substance Abuse in the Workplace", dated January 2019, revealed "... Intervention. A) An employee who has a reasonable suspicion that another employee is impaired is to report his/her suspicions to either the suspected employee's immediate supervisor or the Director of Human Resources. 1. An oral or written report is acceptable. 2. The report includes factual descriptions of the incidents, which led to the belief that the employee may be impaired. 3. The reporting employee reports only facts such as bizarre behavior, repeated unexplained errors, frequent disappearances from work area, or errors in judgement, and not his/her own conclusions about the causes for the behavior. B) The immediate supervisor discusses the incidents with the employee who filed the report and notified the Human Resources Department, who then coordinates an investigation of the situation ... ."
Review of the policy "Physician Health Policy", dated June 2019, revealed "... Purpose: To institute a Medical Staff Physician Health Program. To prevent patient harm and to identify and manage matters of Medical Staff Members' health and/or impairment independent of the disciplinary process. Policy: I. Scope. The purpose of this program includes physician's physical and mental health issues and substance abuse behaviors that have the potential to affect patient care negatively ... Physical Health issues, emotional health issues, and substance abuse can compromise the performance of otherwise fully competent medical professionals so as to require intervention. Such impairments can endanger the total quality of patient care ... II. The Reporting Process. A. All concerns will be reported to one of the following: Hospital President, Medical Staff President, Department Chief, Chief Medical Officer, and Chairman of Medical Staff Quality Committee ... 2) Referral by colleagues who are involved with common care of patients may prevent any quality issues. 3) Referral by the general hospital staff will be via completion of a problem form and sent to the hospital President. This will bypass the ordinary chain-of-command to keep this as confidential as possible. The identity of the staff member will be protected. B. Once the report is made to one of the people mentions in item "A" above, that person shall investigate the validity of the complaint. If at that point there is a concern, it will be reported to the Physician Health Committee ... Physician Health Committee ... Function: 1) Support the approved Physician Health Policy. 2) Perform in an advocacy/advisory role in identifying the impaired or disruptive physician ... 4) Provide on-site intervention, support, counsel, and follow-up on an impaired physician. 1) The Physician Health Committee has the authority to meet with the individual(s) who prepared the report. 2) The Physician Health Committee shall meet with the affected Medical Staff member ... IV. Education. A. Medical Staff. Education of the Medical Staff will be directed mainly to the process of how we report any incident whether this be: 1. Self-referral by the individual physician; or 2. A referral is made to the hospital President, Medical Staff President, Department Chief ... B. Hospital Employees. The education will have to focus on identifying behavior of impairment such as physician having slurred speech, ataxia, or difficulty relating to the employees. The focus will be on the process for reporting the incident not through the regular chain-of-command but to fill out a problem form and report that directly to the hospital President ... ."

1. Interview with EMP23 on November 14, 2019, regarding concerns over impaired physician, "Staff are to immediately tell the manager or Chief of Surgery/Anesthesiology. I was informed by EMP11 who was informed by staff that the doctor was acting oddly. They went to the Chief of Surgery. They said the doctor seemed off ... EMP10 said (they) would "watch (the physican)." I filed it up to EMP8 ... EMP10 is ultimately in charge ... ."

2. Interview with EMP15 and EMP17 on November 15, 2019, at 9:00AM, was conducted. EMP17 stated "The following day, I received a call from EMP8. (They) said the doctor (EMP9) was acting odd, and that there were reports received from leadership team the day before. People in the OR went to EMP10 and said (the doctor) was not acting appropriately. This got brought our attention after the fact." EMP15 stated "I called EMP12 and EMP11 due to reports received by them ... We didn't receive the complaint about EMP9 until the next day." EMP17 and EMP15 were asked about the process when there is concern about an impaired surgeon. They stated that if it is reported to the leader, it should then go directly to HR, and they stated that they would also call EMP8. Both continued by stating that OR leadership did not follow the policy, and that concerns did go to EMP10. Both stated that OR Leadership should have called HR that day.

3. An interview with EMP10 on November 15, 2019, at 11:15AM, revealed "... I don't think it was brought to my attention. Today was first day I knew about this. EMP8 didn't tell me ... ."

4. Interview with EMP12 on November 15, 2019, revealed "There were no concerns until later in the day, around three or four. The circulator had concerns about EMP9. (They) felt EMP9 was impaired ... I found EMP10 and brought to (them) the concerns. I asked EMP9 to check the ... locker room ... EMP10 said (they) would observe EMP9 the next day and to call EMP8. I spoke to EMP8 and they told me to reach out to the appropriate people ... EMP46 had gone to EMP13 earlier in the day. EMP13 talked to EMP9 ... ."

5. Interview with EMP39 on November 15, 2019, at 11:55 AM, revealed "I was late stay. I did relief in that room. EMP9 just wasn't (themselves) ... EMP9 was slurring and staring into space. This was already known before I went into the room. The next day I talked to EMP12 ... ."

6. Interview with EMP46, on November 15, 2019 at 11:40 AM, revealed "... EMP9 just wasn't (themselves) ... I talked to EMP13 ... EMP12 spoke to EMP10 and EMP8. Not sure if we have a policy for this. I went to EMP13. On the Tuesday after this we were told to call HR (Human Resources). I was not aware of this."

7. Interview with EMP20 on November 15, 2019 at 11:45 AM, revealed "... EMP9 wasn't (themselves) ... I mentioned this to EMP46 I talked to EMP13 ... Before the last case I didn't feel safe. I thought EMP9 was impaired ... That was the last case of the day. EMP12 talked to me before the last case around lunch time. EMP12 knew how uncomfortable I was ... I thought we were to follow the chain of command, EMP13, EMP12, EMP10. I didn't talk to EMP10, but I know that (they) knew about it."

8. Interview with EMP13 on November 14, 2019, at approximately 10:00 AM revealed, "I've never heard of anything about a surgeon being incapacitated ... ."
9. Interview with EMP11 on November 18, 2019 revealed "... The staff felt EMP9 was a little off that day ... The day in question, EMP12 went to the Chief of Surgery and staff brought it to my me. EMP10 said (they) would look at it a different day. EMP10 chose not to investigate that day. EMP12 and I did what we could."

10. Interview with EMP12, on November 15, 2019, revealed "There were no concerns until later in the day, around three or four. The circulator had concerns about EMP9. (They) felt EMP9 was impaired ... I went looking for EMP9. I found EMP10, and brought to (them) the concerns. I asked EMP10 to check the ... locker room ... EMP9 said (they) would observe EMP9 the next day and to call EMP8. I spoke to EMP8 and (they) told me to reach out to the appropriate people ... I went to EMP33, EMP10, and EMP8. I didn't know about HR (Human Resources). We did a morning huddle. Staff were told to go the supervisor and report any concerns. EMP46 had gone to EMP13 earlier in the day ... ."

Based on a review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to follow adopted policy related to surgery delays for one of one physicians reviewed.

Findings include:

Review of policy entitled "Scheduling Surgical Procedures", dated April 2019, revealed "... Purpose: To establish a process for scheduling surgical procedures ... Delay Starting Cases: A. It is the surgeon's responsibility to notify the OR Front Desk if he/she will be unavailable to start a surgical procedure at the scheduled time. If the surgeon is not able to begin the procedure within 30 minutes of the scheduled time, his/her case may be delayed while an add-on-case is performed. Additionally, if the late arrival will delay the start time of the following surgeon, the late surgeon will have his/her cases delayed such that the following surgeon will be able to start his/her cases on time. B. Three episodes of greater than 30 minutes late in a 3-month time frame will result in the surgeon receiving a letter from the Chief of Surgery, and the surgeon's room supplies will not be opened until he has physically checked in with the SSPU and notified the OR Front Desk. A case ready to start may also be moved into this room. This will continue for the next 90 days as the arrival times are monitored for improvement. Cancellation of Surgery: A. Once a case is scheduled, only the surgeon (or designee), anesthesiologist or the patient may cancel it ... ."

1. Surgical Reports dated August 1, 2019-November 14, 2019, were reviewed. It was noted that there were three instances associated with EMP9, related to delays and then subsequent surgical cancellations. Surveyor requested associated medical records were for review.
2. Review of MR12, dated 8/6/19, revealed "... Surgical Documentation ... 8/6/2019 06:12 ... Arrival Date and Time: 8/6/2019 06:05 ... Reason for Visit: Outpatient Surgery ... 11:25 ... surgery cancelled due to dr. not here ... ."
Review of MR13 dated 8/12/19, revealed "... Arrival Date and Time: 8/12/2019 08:06 ... 11:20 ... surgery rescheduled ... ."
Review of MR14 dated 8/6/19, stated "... Arrival Date and Time: 8/6/2019 07:59 ... 11:30 ... surgery cancelled due to dr. not here ... ."
3. Interview with EMP12 on December 19, 2019, revealed, regarding surgical start delays, "I asked for repercussions, I didn't get anywhere with that. We do track data, and it goes to EMP10 ... ."
4. Interview with EMP17 on December 30, 2019, confirmed that EMP9 did not receive a letter as described in the facility's policy, related to delays.
Cross reference with:
482.13 (a) Notice of Rights