HospitalInspections.org

Based on review of facility policy and procedures, medical records (MR), and staff interview (EMP), it was determined the facility failed to provide care in a safe setting by competent personnel, for one of 22 medical records reviewed. (MR1)
Findings include:
Review of the facility's "Patient Safety Plan", last revised 8/1/2021, revealed: "... It is the Allegheny Health Network (AHN) philosophy that every patient has the right and should expect the delivery of safe medical care. ... " .
Review of the facility's "Patient Rights and Responsibilities" policy, last revised 5/24/2021, revealed: " ... F. Care Delivery: You have the right to: 3. Receive kind, respectful, safe, quality care delivered by skilled staff. ... ".
Review of MR1 revealed that MR1 was admitted to the facility on September 8, 2021. Continued review of MR1 revealed an ED Provider Note filed September 9, 2021 at 6:23 AM, which indicated: " ... I was called to room for unresponsiveness. Patient was pale, blue, unresponsive. He was found to be in Vfib on the monitor. CPR was initiated. ... nursing staff recalled that [MR1] is DNR, and DNI. CPR was halted at this time. ... "
Further review of MR1 revealed there was no evidence of a DNR order in the MR1's medical record.
During an interview with EMP3 on October 18, 2021, at approximately 9:50AM, EMP3 stated that a POLST belonging to another patient was found and the ED physician was incorrectly notified that he could stop CPR.
During an interview with EMP1 on October 18, 2021, at approximately 2:50 PM, EMP1 confirmed a nurse who did not complete competencies for ED staff, responded to the code on 9/9/21 and provided inaccurate information about MR1's code status.