HospitalInspections.org

Based on a review of medical records (MR), facility documents and interview with facility staff (EMP), it was determined that Conemaugh Miners Medical Center failed to identify a patient at risk of self harm, and failed to follow their adopted procedure related to Triage, by failing to ensure the immediate availability of nursing personnel so as not to delay the initial assessment of patients presenting for emergency care in 11 of 30 patients (MR17, MR18, MR19, MR20, MR21, MR23, MR24, MR25, MR26, MR27 and MR28).


Findings Include:

Policy Stat ID: 6119805 ... Last Reviewed: 03/2019 ... Patient Rights Statement of Policy: It is the policy of Conemaugh Health System (CHS) to respect the rights of patients during their hospitalization and to recognize that each patient is an individual with unique health care needs, staff will provide considerate, respectful care, incorporating patient's personal values and belief system and strive to protect each patient's dignity. CHS acknowledges that the patient has the right to make decisions regarding medical care ... Information regarding the patient's rights and responsibilities is made available to all patients ... Conemaugh Health System is committed to providing quality care to all patients and to make their visit as pleasant as possible. Our concern and respect for you, our patient, is addressed in this Statement of Patient's Rights. 1. You have the right to respectful care given by skilled staff. 2. You have the right to receive care no matter what ... 3. You have the right to treatment of symptoms that may be associated with your illness. You have the right to expect prompt response to your report of pain. ... 8. In case of emergency, you can expect emergency treatment without delay. 9. You have the right to quality care and high professional standards that are always kept and reviewed. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid any personal discomfort. ... ."

Conemaugh Miners Medical Center ... Policy Stat ID: 5759086 ... Policy Area: Nursing Admin ... Patient 1:1 Observation for Destructive Behavior policy and procedure dated December 2018. "Statement of Policy. 1:1 Patient Observation is safety measure to provide a 1:1 staff/patient ratio for the patient found by clinical assessment to be exhibiting behavior that may be harmful/risky to self or others. The observer stays with and observes the patient continually. The Nursing suicidal risk assessment may also identify a patient who is at risk for suicide. The patient's rights, safety, and dignity are preserved. ... ."

Conemaugh Miners Medical Center ... Policy Stat ID: 5759005 ... Policy Area: Nursing Admin. ... Suicide Risk Assessment/Suicide Precautions policy and procedure dated December 2018. "Scope: This policy applies to all patient care areas within Miners Medical Center (MiMC). Purpose: To describe the process for assessing for risk and developing a plan of care for patients 13 years of age and older with suicidal ideations. Risk factors for suicide include but are not limited to: A. Psychological Factors: history of suicide attempt, history of deliberate self-harm, comorbid alcohol and other substance disorders, current or past psychiatric disorders particularly mood disorders, schizophrenia, anxiety, personality disorders, history of trauma or physical or sexual abuse, major physical illness, chronic pain, family history of suicide, history or violent or aggressive behavior, triggering event leading to humiliation or despair, loss (job, financial, relational, social) ... Policy: The approach to the care of the suicidal patient is multidisciplinary. At a minimum, all patients aged thirteen years and older entering the Emergency Room for care or admitted to MiMC who present with a behavioral health related complaint or show signs/symptoms of being a self-harm risk, will be screened using the screening tool found in the electronic medical record (EMR). A Registered Nurse (RN) will assess the patient for suicide risk by completing the questions in the EMR found under 'Suicide Screening.' ... If a behavioral health patient is not deemed at risk for suicide based on the screening, they must be reassessed for suicide risk every four hours. The 'Suicide Screening' should be completed on any behavioral health patient at least every 4 hours for an [sic] change in mental status. Documentation by an RN must be completed in the EMR that the risk for suicide was reassessed. At any time that the suicide risk becomes positive, the process will be as follows: If the patient answers 'yes' to either questions 1 or 2, the patient must be on a one to one (1:1) and the 'Suicide Risk Patient Room Checklist' must be completed immediately. ... The RN and/or the physician may order for 1:1 observation. This must both be physically ordered in the EMR and documented. ... 6. When a patient is determined to be at risk for suicide through screening, regardless of the level of risk, the patient's safety is maintained. The Nursing Supervisor is notified and patient is placed on immediate 1:1 observation. ... ."

Conemaugh Miners Medical Center ... Policy Stat ID: 6835040 ... Policy Area: Nursing Emergency Dept. ... Psychiatric Patients Including Suicidal Protocol policy and procedure dated August 2014. "Purpose: To provide for the assessment and short-term management of the psychiatric patient, including suicidal patients. ... Policy: Psychiatric patients, including suicidal patients, will receive careful consideration of both physical and psychological needs. A definite follow-up plan to ensure safety of the patient will be formulated for each patient, and admission to an appropriate facility will be arranged as needed. ... The emergency physician will ensure the availability of a psychiatric or psychological consultant for every suicidal patient as needed. Room 211 is a seclusion room and can be used as an extension of the ER if needed. Policy Implementation Statements: Registered Nurse will perform an initial physical and psychological assessment. ... Assure that a staff member remains with the patient at all times. Prevention of self injury and injury to others by ... Determine from family, prehospital personnel , etc. if the patient has had past mental illness, hospitalizations, injuries or serious illnesses, used alcohol or drugs or has experienced crisis in interpersonal relationships. Proceed per emergency physician's orders in regards to medications given. Emergency physician will consult with patient's personal physician. Emergency physician determines probable need for admission of certain patients to ensure proper care of the patient. Emergency physician also determines need for immediate or delayed psychiatric or psychological consultation. Crisis will be notified for all patients ... If patient is under the influence of alcohol or needs medical stabilization admission to the hospital is required before psychiatric treatment will be instituted. Crisis is notified. Caseworker will determine when the consult and transfer will be made. ... ."


Conemaugh Miners Medical Center ... PolicyStat ID: 4718713 ... Policy Area: Nursing Emergency Dept. ... Admission to the Emergency Department policy and procedure dated July 2019. "Purpose: To provide a systematic method for assessment and treatment of Emergency Department patients. Level of Personnel: Registered Nurse, Outpatient Clerk Policy: ... The immediacy by which patients are seen is determined by triage policy. Procedure: Assessment by RN including history and vital signs is completed when the patient is triaged. ... ."
Conemaugh Miners Medical Center ... PolicyStat ID: 6718119 ... Policy Area: Nursing Emergency Dept. ... Triage System dated July 2019. "Policy: All patients presenting for treatment will be evaluated and assessed by an Emergency room R.N. This Triage nurse will make an urgency determination and direct patients to appropriate care area. The Outpatient Clerk will alert ER staff of patient's arrival by using bell system. Purpose: To assure that all patients presenting to the Emergency Department for treatment are treated with the most critical/severe being seen first. This assures that those with life threatening illnesses will not have to wait for treatment. ... Procedure: ... Emergency RN will triage and assess patient to determine nature of complaint and determines urgency of visit. ... After triage, some urgent (depending on patient status) and all non-urgent patients will be permitted to register and will be directed to the Waiting area Patients are not triaged out of the Emergency Department. They are triaged to the main ER care area only. ... The RN will facilitate patient flow by calling patients into the ER area and assigning rooms, preparing the patient for exam and notifying the MD of the patient's presence. All RN's assist with patient care in the main treatment area and assist with triage as assigned. ... ."

Conemaugh Miners Medical Center ... PolicyStat ID: 6717478 ... Policy Area: Nursing Emergency Dept. ... Emergency Department Nursing Assessment policy and procedure dated July 2019. "Policy: A nursing assessment will be completed on all patients seen in the Emergency Department. The Nursing Assessment Form will be completed in triage, or when the patient is immediately admitted to a treatment room within the Emergency Department, depending on the patient's condition and means of arrival. Procedure: The patient will be brought into the Triage Area or the Emergency Department and an assessment will be completed and a Triage note in the EMR. ... ."

Conemaugh Miners Medical Center ... PolicyStat ID: 6900517 ... Policy Area: Nursing Emergency Dept. ... Assessment-Reassessment policy and procedure last revised October 2015, last approved September 2019. "Scope: ... Purpose: To ensure patients who enter the Emergency Department seeking care will receive an assessment and reassessment regardless of the location in the Emergency Department. The purpose of triage in the emergency department (ED) is to prioritize incoming patients and to identify those who cannot wait to be seen. The triage nurse performs a brief, focused assessment and assigns the patient a triage acuity level, which is a proxy measure of how long an individual can safely wait for a medical screening examination and treatment. The goal for patients who initially present to the ED is to ensure a rapid assessment and subsequent reassessment if necessary based on the ESI level and timeliness to a qualified medical provider. LifePoint EMTALA policies and procedures will be followed. Policy: The assessment process can be divided into 3 categories: Rapid initial assessment Comprehensive history and assessment Reassessment. The rapid initial assessment time goal for LifePoint facilities is 10 minutes of arrival. The rapid initial assessment should be based on the presenting chief complaint, vital signs, and information needed to complete the ESI level. A comprehensive assessment can be initiated if a provider is not immediately available. A more comprehensive evaluation can follow the rapid initial assessment and does not require the patient to be in the location of triage. The rapid initial assessment may include but is not limited to: Airway, Breathing, Circulation, Disability, (Neuro) Pain, if needed to evaluate acuity level. Pregnancy, Vital Signs ... A reassessment process will be in place for each facility. The depth of the reassessment is focused upon the chief complaint, pain levels, vital signs, and age of the patient. Procedure: Upon presentation, the triage nurse uses critical thinking skills and ESI (Emergency Severity Index System) guidelines to determine the priority of need for care. Patients are seen in order of the assigned triage level which assists in predicting potential for demise. ... All patients waiting greater than one hour-regardless of location in the Emergency Department-will be reassessed at least hourly or more often as indicated following the Rapid Initial (Triage) Assessment. Depth of reassessment is focused upon presenting complaint, and documentation elements may include: Current state of chief complaint (i.e. active bleeding from thumb laceration) Vital signs if appropriate (i.e. if patient presented for fever, a temperature is appropriate to document) Pain level, if applicable Responses to nursing interventions, if initiated (i.e. ice pack applied to bee sting, swelling decreased) After Medical Screening Exam is initiated, the facility will have a policy that defines reassessment periods during the course of patient treatment determined by chief complaint, acuity, condition, symptoms, treatments and orders. Suggested minimum is one hour. ... ."

1. Review of MR1 [Conemaugh Miners Medical Center]: "Medical Command Record ... Date 6/10/19 Time: 1543 ... Patient History Information: Mood Disorder with Psychosis ... Patient was open about medical history of having mood disorder with psychosis. ... ."

"... ED Triage Notes ... 06/09/19 1553 ... Pt present co inability to ambulate-states walking for past 8 hours-'can't walk any more' ... ED Provider Notes ... 1812 ... Chief Complaint ... Difficulty Walking ... 35 year old patient brought in by EMS. Patient was driving to New York when they ran out of gas or broke down. Patient had been walking for ... 8 hours when they stopped because their feet hurt. Patient went to a residence and the occupants called EMS who brought patient to the ED. According to the patient has a long psychiatric history and is to be on medications which says has not been taking for the past few days. ... Home Medications: No Medications Reported ... Review of Systems ... Physical Exam Constitutional: ... Musculoskeletal: Few blisters on the contact surfaces between the 2nd and 3rd toes on the right. Psychiatric: mood: appears anxious. ... is agitated and hyperactive. Cognition and memory are normal. ... expresses impulsivity. ... exhibits depressed mood. ... Final Diagnosis: None ... ED Course ... 1918 ... Patient's parents are driving from Maryland with medications and plan to take patient home. ... 1920 ... ED Notes ... 06/09/19 2125 ... Pt left, refusing to come back in hospital, Supervisor notified, unable to find pt on hospital grounds, Police notified. ... ED Notes ... 06/09/19 2200 ... Pt left without further Tx, Police notified. PSP arrived explained that pt left, and is not familiar with this area. Supervisor notified. ... ED Provider Notes ... 06/09/19 2200 ... Pt was handed off to me at 7 pm by the out-going emergency department physician, as a pt that just needed time waiting for family to pick up, already placed at discharge. Parents were coming from North Carolina and it was going to be a while. Pt eloped before parents arrival. At no time did I see the patient. ... ."

MR1 Patient Care Timeline ... 6/9/2019 15:53 Patient Arrived in ED ...
15:53 Triage Started ...
15:53:54 Chief Complaints Updated: Difficulty Walking ...
15:53:56 ED Triage Notes: Pt present c/o inability to ambulate -states was walking for past 8 hours -'can't walk anymore' ...
15:54:53 Patient roomed in ED To room ER 06 ...
15:55 Pain Assessment ... Pain Score: 8 -Severe pain ...
15:55:12 Acuity 5 Selected ...
15:55:12 Triage Completed ...
16:04 Pain Assessment ... Pain Score: 7, Severe Pain, Pain Type: Acute ...
16:09 First Provider Evaluation ... 18:02 ED Quick Updates ... Testing updates: Nurse Monitoring Patient ...
18:02 Pain Assessment No/denies pain ... Pain Score: 0-No pain ...
18:03 ... Peripheral IV ... Insertion attempts: 3 ... Left; Upper Arm Assessment Line Status: Blood return noted; infusing Dressing Intervention: New dressing ...
21:11 ED Quick Updates ... Patient Uncooperative/Combative (phone given multiple times - to call home) Testing updates: Nurse Monitoring Patient ...
21:16 ED Quick Updates ... Supervisor called to ER, pt left the ED and was found on Helipad, and had to be removed by Flight Crew and ER staff, patient independently returned to ED room and verbalized understanding that they must remain in room until parents arrive, pt was observed leaving the ER refusing to return, 911 called by RN
21:35:07 ED Notes: Pt left refusing, to come back in hospital, Supervisor notified. Unable to find pt on hospital grounds. Police notified. ...
21:43:25 Patient transferred from room ER6 to room OV2 ...
22:00 ED ... ED disposition set to AMA ...
22:00 ED Notes: Pt left with out further Tx. Police notified. PSP arrived explained that pt left-and is was not from this area. Supervisor notified. ... ."



2. MR1 failed to reveal documented evidence of a suicide screening assessment upon admission to the Emergency Department at 3:53 PM, during Triage. MR1 also failed to reveal documented evidence of a suicide screening reassessment following the physician's physical exam at 6:12 PM which stated the patient's mood appears anxious, was agitated and hyperactive, and expressed a depressed mood. MR1 failed to reveal documented evidence of a suicide screening reassessment following a change in behavior at 9:11 PM when the patient became uncooperative/combative, and MR1 failed to reveal documented evidence of a suicide screening reassessment following elopement from the hospital on to the tarmac towards the helipad/return to hospital with assist of ED staff and flight crew, at approximately 9:16 PM.

3. Telephone interview with EMP22 on July 30, 2019, at approximately 8:30 AM. "... In Triage the patient did not voice any suicidal ideations. Physician did order x-rays and did not find any thing medically wrong. The patient's parent was on the way up from Maryland with patient's medications. ... The first time that patient ran out of the ED, we brought them back in. The second time the patient ran out and was going towards the helipad. The helicopter was on the tarmac and the pilot and crew assisted the patient back into the hospital. ... When the patient was found on Number 9 Road, the Police called EMS and the patient was transferred to [tertiary care center]. It would have been my fault is something happened to the patient. ... ."

4. Telephone interview with EMP19 on August 22, 2019, at approximately 2:00 PM confirmed that there was no documented evidence of a suicide risk assessment at Miners in MR1, no documented evidence of a physician order for one to one observation, and no documented evidence of physician orders for any Lab work or Radiology studies. EMP19 revealed, "I can't see any physician orders at all except for an IV that was d/c'd and a supper tray."

5. Telephone interview with EMP3 on August 23, 2019, revealed, "The expectation is that each patient would have a suicide risk assessment, fall risk and safe home assessment. ... ."
EMP3 confirmed "... There was not a suicide risk assessment completed on MR1. ... ."

6. Facility documentation dated September 6, 2019, from EMP3 revealed, "We do not have any specific policy pertaining to pain assessment and reassessment. There was no pain medication ordered and no wound care completed. I did check all the orders and dictations from EMP23 and there was never any xray's orders. ... ."


7. Review of MR30 [Tertiary Care Center where MR1 was taken to following ED elopement]: "... ED Triage Notes ... 06/10/19 0412 ... Pt found in woods after running away from Miners Hospital. ... Per EMS report, pt has a long psych hx and has not been taking medication. ... ED Provider Notes ... 06/10/19 0431 ... Chief Complaint: Psychiatric Evaluation ... The patient was reportedly being seen for a psychiatric evaluation at Miner's Hospital when patient eloped. Was found in the woods near Miner's Hospital by EMS, brought to ... Hospital for further evaluation. The patient reports a history of bipolar disorder for which they are prescribed ... but states has not been taking these medications for the past 4 days. ... denies SI or HI. Patient has a history of SI but denies at this time. ... Patient is unsure where they are now or how they ended up here. ... Patient also has evidence of acute psychosis that will likely need to be evaluated by Psychiatry however patient is not medically stable for the inpatient Psychiatric Unit at this time. The patient is agreeable to staying in the hospital and has been compliant since has been here. ... Diagnostic Impression: 1. Rhabdomyolysis 2. Acute psychosis (CMC/HCC) 3. Bipolar affective disorder, remission status unspecified (CMS/HCC) 4. Medically noncompliant. Disposition: Observation. ... Currently stable, in bed, on 1:1 with IVF running. ... A/P: Continue to monitor Lab work for Rhabdomyolysis. Psychiatry evaluation pending. Will likely be discharged to Psychiatry once medically stable. ... Schizoaffective disorder/bipolar disorder, poorly controlled with medical noncompliance Consult Psychiatry Patient high risk of elopement and likely danger to self/others 1:1 monitoring for safety ... ."


8. Review of Conemaugh Miners Medical Center, Patient Safety, Clinical Quality Committee Meeting Minutes dated January 8, 2019, March 12, 2019, April 9, 2019, May 14, 2019, and June 11, 2019, was completed. The minutes reflected activities/reports/discussion including, but not limited to a review of incidents/events specific to left without being seen and left against medical advice patients.

9. Interview with EMP3 on July 25, 2019, at approximately 1:00 PM revealed, "... Our triage goal is two to eight minutes, no longer than 10 minutes."


10. Review of MR12-MR16 revealed no documented evidence of Triage assessment performed by the ED RN. MR13-MR16 also failed to revealed documented evidence of the completed Consent to Leave Hospital Without Being Seen by Physician/Provider form.

MR12 dated December 2, 2018, revealed that the patient arrived to the ED at 12:57 PM complaining of ... , then patient left without being seen at 4:45 PM. Consent to Leave Hospital Without Being Seen by Physician/Provider was signed by the patient and witnessed at 4:45 PM.
MR13 dated December 26, 2018, revealed that the patient arrived to the ED at 8:18 PM complaining of ... , then the patient was not in Waiting room when called for triage at 9:29 PM.
MR14 dated December 26, 2018, revealed that the patient arrived to the ED at 6:30 PM complaining of ... , then patient left without being seen at 7:11 PM.
MR15 dated January 12, 2019, revealed that the patient arrived to the ED at 1:55 PM complaining of ... , then patient left without being seen at 3:10 PM.
MR16 dated February 25, 2019, revealed that the patient arrived to the ED at 4:50 PM complaining of ... , then patient left without being seen at 5:57 PM.


11. MR17, MR18, MR19, MR20, MR21, MR23, MR24, MR25, MR26, MR27 and MR28 revealed documented evidence of RN Triage assessment, however, all failed to meet the facility's expectation for timely Triage Assessment.
MR17 dated January 12, 2019, revealed that the patient arrived to the ED at 3:49 PM, complaining of ... and at 4:24 PM ED Triage Notes ... ."
MR18 dated January 13, 2019, revealed that the patient arrived to the ED at 2:43 PM, complaining of ... , at 2:50 PM the Nursing Supervisor provided patient with an ice pack, and then at 3:50 PM ED Triage Notes revealed, "... spoke with patient/parents and they are going to see dentist ... and then will return later for laceration repair. ... ."
MR19 dated January 14, 2019, revealed that the patient arrived to the ED at 4:31 PM, complaining of ... , at 4:54 PM ED Triage Notes revealed, ... .'"
MR20 dated February 24, 2019, revealed, that the patient arrived to the ED at 1:31 PM, complaining of ... and at 2:33 PM ED Triage Notes revealed, " ... ."
MR21 dated February 27, 2019, revealed, that the patient arrived to the ED at 11:00 AM, complaining of ... and at 12:40 PM ED Triage Notes revealed, "... ."
MR23 dated March 16, 2019, revealed, that the patient arrived to the ED at 2:06 PM, complaining of ... and at 2:40 PM ED Triage Notes revealed, "... ."
MR24 dated March 18, 2019, revealed, that the patient arrived to the ED at 8:06 PM, complaining of ... and at 9:02 PM ED Triage Notes revealed, " ... ."
MR25 dated March 22, 2019, revealed, that the patient arrived to the ED at 3:54 PM, complaining of ... and at 4:23 PM ED Triage Notes revealed, "... ."
MR26 dated April 2, 2019, revealed, that the patient arrived to the ED at 8:09 PM, complaining of chest pain and at 8:20 PM ED Triage Notes revealed, "... ."
MR27 dated April 5, 2019, revealed, that the patient arrived to the ED at 5:39 PM, complaining of ... and at 6:07 PM ED Triage Notes revealed, " ... ."
MR28 dated April 7, 2019, revealed, that the patient arrived to the ED at 6:17 PM, complaining of ... and at 7:02 PM ED Triage Notes revealed, "... ."

Based on a review of facility documents and staff interview (EMP), it was determined that Conemaugh Miners Medical Center failed to follow adopted Board of Trustees Bylaws and failed to have Institutional Plan and Budget prepared under the direction of the Governing Body.

Findings include:

Board of Trustees Bylaws of Conemaugh Miners Medical Center "... Article I - General Scope. Be it resolved that the bylaws set out below shall govern the transaction of the business and affairs of the Hospital. 1.1 Purpose: The purposes, goals and objectives of the Board of Trustees of Conemaugh Miners Medical Center shall be to 1.1(h) Provide for overall institutional planning, with participation of the Medical Staff, nursing department, and such other individuals as the Governing Body deems appropriate; and ... Approved by the Chair of the Board of Trustees October 24, 2017."

1. Interview with EMP1 on July 25, 2019, at approximately 2:30 PM, confirmed the Board of Trustees Meeting Minutes had no mention of the institutional plan or budget.

2. Interview with EMP1, on July 26, 2019, at approximately 10:35 AM, confirmed that the Board of Trustees does not have the authority to approve budgets and stated that the Board does not have over-sight for financial budgets.

Based on a review of facility documents and staff interviews (EMP), it was determined that Conemaugh Miners Medical Center failed to follow their adopted Performance Improvement Plan, by failing to ensure that an evaluation was conducted on all contracted services furnished within the hospital.

Findings include:

Board of Trustee Bylaws of Conemaugh Miners Medical Center, "... Purpose: ... Maintain a commitment to continued comprehensive quality assurance and quality improvement in all aspects of health care provided by the Hospital in cooperation with the Medical Staff, CEO and hospital personnel ... The responsibilities and obligations of the Board shall include ... Establishing, maintaining and supporting, through the CEO and the Medical Staff and its designated committees a comprehensive, hospital-wide program for quality assessment and improvement ... ." Approved by the Chair of the Board of Trustees October 24, 2017.

Conemaugh Miners Medical Center 2019 Patient Safety and Clinical Quality Performance Improvement Program, dated January 2019. "... The Board of Trustees ... has the overall responsibility for the safety and quality of the care, treatment, and services provided by all providers and employees ... Department Managers/Directors and staff members participate in the improvement of health outcomes and preventing and reducing patient harm by planning, designing, measuring, aggregating, analyzing, implementing and evaluating interdepartmental and intradepartmental processes. This is accomplished through participation on Hospital Committees, interdisciplinary Performance Improvement Teams and/or departmental PI activities ... Department Managers are responsible for complying with LPNT [LifePoint] company dashboards and/or developing service line dashboards which measure and monitor regulatory-required quality control indicators at the service line level. Additionally, when hospital services are provided through a contract service or through an off-site health organization, the Manager and the appropriate Medical Director are responsible for monitoring and evaluating these services ... ."

1. Surveyor requested a List of Contracted Services, and facility evaluations of contracts. Facility provided a list of approximately 207 contracted services, with approximately 24 being described as clinical.
Surveyor was also provided with a blank facility form entitled, Annual Contract Service Evaluation Summary.

Facility was unable to provide surveyor with documentation that the Annual Contract Service Evaluation Summary was completed for all contracted services furnished within in the hospital.

Based on a review of facility documents and interview with staff (EMP), it was determined that Conemaugh Miners Medical Center failed to follow adopted staffing policies and facility expectations to ensure the immediate availability of a Registered Nurse for bedside care of all patients.

Conemaugh Miners Medical Center ... PolicyStat ID: 6713053 ... Policy Area: Nursing Admin ... Hospital Plan for the Provision of Nursing Care policy and procedure dated July 2019. "The intent of Conemaugh Miners Medical Center's plan for the provision of nursing care is the safe delivery of appropriate and effective care to all patients and the development of an atmosphere conducive to staff development ... The Nursing Department will provide care according to the scope of nursing practice set by the Nurse Practice Act of Pennsylvania and the Health Department rules and regulations regarding hospital licensing. Nursing care shall be defined as ... which enable nurses to coordinate the total nursing care for patients. The purpose of nursing is to provide care, treatment, and health teaching for ... Miners Medical Center is a 30-bed acute care hospital offering a full range of medical services. ... Miners Medical Center provides care according to a Master Staffing Plan based upon projected patient census and acuity demands. The Master Staffing Plan is designed to meet nursing needs of the patients in conjunction with the hospital's mission. Fluctuation in census and or patient acuity necessitating adjusting to the Master Plan are made with the use of part time, float and relief staff. Additional needs are met via the use of overtime as appropriate. The Master Staffing Plan is available through the Vice President of Nursing. The hospital plan for nursing care is designed to support improvement and innovation in nursing practice via adherence to and/or appropriateness of the Master Staffing Plan as monitored on an ongoing basis through the Departmental Budget reports (Comparing the actual census activity, historical data and review the acuity demands with Nursing Daily Staffing Worksheet). ... The Hospital Plan for Provision of Nursing Care is reevaluated, as needed, according to changing patient needs and at least annually in conjunction with budget process. Consideration is given to changes in the patient population, new programs, feedback from patients, families, significant others, physicians, and staff along with review of Quality Assurance findings, patient outcome indicators and nurse staffing requirements."


Conemaugh Miners Medical Center ... Policy Stat ID 6732794 ... Policy Area: Nursing Admin ... General Standards of Nursing Care policy and procedure dated July 2019. "The standards of nursing care of the Department of Nursing shall reflect the philosophy of the department. The Department of Nursing shall facilitate the provision of a safe environment for patients, employees and visitors. The Department of Nursing shall provide nursing care based on assessment of the needs of the patients and family. ... The Department of Nursing shall support the concept of Modified Primary Nursing by ensuring that each patient is assigned appropriately and that consistent care is provided by the following plan of care. ... ."

Conemaugh Miners Medical Center ... PolicyStat ID: 6732855 ... Policy Area: Nursing Admin ... Objectives of the Nursing Service Department policy and procedure dated July 2019. "... Identify needs to administration and medical staff ... Provide high quality individualized care in a safe environment to meet the total needs of the patient, regardless of age, as determined through nursing assessment. ... Plan for provision of continuous nursing services to meet the patient's needs ... Assure the level of scheduled personnel are qualified to meet the needs of the patient ... Promote cost containment ... Provide a mechanism for monitoring staff performance and the quality of nursing care. ... ."

Conemaugh Miners Medical Center ... PolicyStat ID: 6717653 ... Policy Area: Nursing Emergency Dept. ... Nursing Staff dated July 2019. "Purpose: To provide guidelines for nursing staff in the Emergency Room. Policy: The Department of Nursing will provide personnel in sufficient number and expertise to facilitate the function of Emergency Service. Procedure: ... When a shortage of personnel exists during a shift, it will be the responsibility of the Nursing Service Department to provide the required skilled personnel, preferable those having received education and orientation in a critical care area and as per union contract/labor management. All personnel are hired with the understanding that they may be required to rotate through various shifts, but will be given preference of time if possible. ... ."

Conemaugh Miners Medical Center ... PolicyStat ID: 4718824 ... Policy Area: Nursing Emergency Dept. ... Medical Direction and Staffing policy and procedure dated March 2019. "... Staffing the Emergency Department is the function of the Nursing Service Department. At least one Registered Nurse is employed in the Emergency Department on each shift. The number of nursing personnel is sufficient for the types and volume of patients served. This includes a minimum of two (2) Registered Nurses 7-3, two (2) Registered Nurses 3-11, one Registered Nurse 11-7. The nursing staff shall have demonstrated skills in emergency care of patients. In situations where the over-load is such that the physician feels he needs additional help, the Medical Director of the Emergency Department should be contacted by the ER physician. If additional nursing staff is required, the nurse on duty should notify the Nursing Supervisor who will attempt to supply additional staffing. ... ."

"Conemaugh Health System Job Description - Nursing Administrative Supervisor ... Entity: MiMC ... Supervises: Direct supervision of RNs, LPNs, UCs, ... Job Summary: Promotes optimal care for all ... Assumes administrative responsibility for hospital operations. ... Essential Responsibilities: Assists the Patient Care Team to coordinate delivery of patient care ... Promotes safety according to organizational policies and industry standards. Maintains accountability and productivity for appropriate staffing following the departmental staffing plans. ... Responds to emergencies, i.e., codes, strokes, traumas, etc. Serves in Supervisory role for all hospital departments during off shifts and holidays. ... ."

"Conemaugh Health System Job Description ... Entity: MiMC ... Job Title: Registered Nurse (RN), Special Duty-Float ... Department: Medical/Surgical ... The Special Duty RN provides direct day-to-day care to patients and families ... Essential Responsibilities: ... 2. Promotes factors related to safety, effectiveness and cost in planning and delivering patient care. 3. Provides patient assessment throughout patient stay while maintaining a therapeutic partnership with patient, family and caregivers. Provides initial and ongoing assessment and care. ... ."

"Conemaugh Health System Job Description ... Entity: MiMC ... Job Title: Registered Nurse (RN), Special Duty-Float ... Department: Emergency Room ... The Special Duty RN provides direct day-to-day care to patients and families ... Essential Responsibilities: ... 2. Promotes factors related to safety, effectiveness and cost in planning and delivering patient care. 3. Provides patient assessment throughout patient stay while maintaining a therapeutic partnership with patient, family and caregivers. Provides initial and ongoing assessment and care. ... ."

1. Review of staffing schedules and assignment sheets dated June 9, 2019, through June 22, 2019, was conducted with EMP3 and EMP16 on July 25, 2019, at 9:15 AM for the Medical/Surgical Unit and the Emergency Department.

Core staffing for the Medical/Surgical Unit, patient to nurse ratio is six to one as per EMP3. There are no nurse aides or LPNs employed in this area. There were 42 total shift occurrences when broken down into eight-hour shifts. For six of the 42 shift occurrences, there was only one RN scheduled in the Medical Surgical Unit. For four of the six occurrences, the inpatient census was greater than six. EMP3 stated that when there is only one RN on the Medical/Surgical Unit, the RN supervisor assists the Med/Surg RN, however, does not take a patient assignment. There is no documented evidence on the schedule or on the assignment sheets that confirmed the RN Supervisor assisted on the Medical/Surgical Unit.

Core staffing for the Emergency Department is two RNs as per EMP3. There are no nurse aides, ED technicians or LPNs employed in this area. There were 42 total shift occurrences when broken down into eight-hour shifts. For five of the 42 shift occurrences, there was only one RN scheduled in the ED. EMP3 stated that when there is only one RN in the ED, the RN Supervisor is available to assist. There is no documented evidence on the schedule or assignment sheets that confirmed the RN Supervisor assisted in the Emergency Department.

2. Facility documentation revealed, " ... Thu 5/30 ... Hi All, Here are the new schedules for the ER and MS for June 30-July 13 and the updated needs lists. The needs for the new schedule are not on the needs lists. ... It is very difficult with so little staff to give you everything you ask for, I have been trying. ... I am also sending the schedules July 14 to August 24th, as you can see there are numerous needs. There is nothing more I can do to make this better at this time. ... ."

3. Review of ER and Med/Surg Staff Meeting Minutes dated March 21, 2019, revealed, "... Staffing in the ER: EMP20 reported that there continues to be decreased staff in the ER. ... The ER and Med/Surg Staff Meeting minutes dated June 20, 2019, revealed that all ED and Med/Surg nurses attended the meeting with the exception of three who were excused. The minutes revealed, "... Staffing Update: ... [Union Representative] stated that Nursing Supervisors and wage pool staff are not permitted to perform bargaining unit work. ... ER and Med/Surg Staff Meeting minutes dated Thursday, July 18, 2019, revealed, "... EMP11 asked if there is any possibility of utilizing Agency staff. EMP21 reported that it would make more sense to hire an LPN or Nurse Aide than to use Agency staff. ... ."

4. Interview with EMP3 on July 24, 2019, at approximately 9:30AM, revealed, "We don't have LPN's or Nurse aides. ... We have multiple positions open, a total of six. ... We're trying to get a Nurse Aide position, but we need an average daily census of 10 for that ... They don't want Non-Union employees working Union positions [supervisors]. ... ."

5. Interview with EMP6 on July 24, 2019, revealed, "On Friday, I was the only RN in the ED. I couldn't watch telemetry from 7 AM to 3 PM, because We saw six to seven patients during that time. They were staggered, that's only thing that saved us. ... All weekend, we were short. ... We should be staffed with two RNs. Holes in the schedule happen frequently. ... ."
6. Interview with EMP8 on July 24, 2019, revealed, "Staffing is a tough problem. Three RNs left in the beginning of the year."

7. Interview with EMP9 was conducted on July 24, 2019, at 10:45 AM, "... I filled out the unsafe staffing forms for Saturday and Sunday. I was here by myself. ... There was only one nurse in the ER on Saturday and Sunday. ... I've felt unsafe lately. The schedule is posted with a lot of holes. Even four or five patients is a lot for one person. The issue is when there is only one nurse on Med/Surg and one nurse in the ER. All weekend there was one RN in the ER and one on Med/Surg. ... ."


8. Interview with EMP15 on July 24, 2019, at 10:40 AM revealed, "... We've lost seven RN's since February, none were replaced. They knew we were losing people, we lost three in the ER, one in the OR, and lost some floats. They talked about Aides but the Union has something to do with that. ... When I'm by myself, I feel that it is unsafe, and I fill out the staffing form. ... If we had to call a Code or a Rapid Response, there would only be my Manager and myself to respond. There wouldn't be anyone else to watch the other patients. Hopefully, that will never happen. Staff are getting bitter about working by themselves. ... ."

Based on a review of medical record (MR), facility documents and interview with staff(EMP), it was determined that Conemaugh Miners Medical Center failed to evaluate the nursing care provided to a telemetry patient in one of one medical record (MR4).

Findings Include:

Conemaugh Miners Medical Center ... PolicyStat ID: 6713053 ... Policy Area: Nursing Admin ... Hospital Plan for the Provision of Nursing Care policy and procedure dated July 2019. "The intent of Conemaugh Miners Medical Center's plan for the provision of nursing care is the safe delivery of appropriate and effective care to all patients and the development of an atmosphere conducive to staff development which is guided by the hospital's Mission, The Philosophy and the Objectives of the Department of Nursing the policies and procedures approved by the Medical Staff and Board of Trustees is designed to guide the department of nursing in the delivery of care. The Nursing Department will provide care according to the scope of nursing practice set by the Nurse Practice Act of Pennsylvania and the Health Department rules and regulations regarding hospital licensing. Nursing care shall be defined as systematic application of specialized knowledge and skill acquired through the study of biological sciences, which enable nurses to coordinate the total nursing care for patients. The purpose of nursing is to provide care, treatment, and health teaching for individuals who are experiencing changes in the normal health process or who require assistance in the maintenance of health and the prevention and management of an illness, injury, or disability. The practice of nursing by a Registered Nurse shall mean assuming responsibility and accountability for the rules of a practitioner, teacher and consultant. Nursing actions shall include but are not limited to: Providing age specific nursing care based on the assessment of the needs of the patient and family using nursing diagnosis. Executing all age specific nursing treatment regimen through the selection, performance and management of proper nursing practices. Teaching health care practices to patients and their families. Collaborates with the health professional to achieve continuity of patient care. Evaluating patients' responses to nursing intervention. Executing diagnostic and therapeutic regimens prescribed by medically privileged practitioners. Administering, supervising, delegating and evaluating nursing activities. ... ."


The facility was unable to produce any cardiac monitoring or telemetry policy.

1. MR3 Electronic Physician Order dated May 26, 2019, at 5:21 PM revealed, "... Place in Observation ... Level of Care: Telemetry ... Hospital Course: ... [Patient] was monitored overnight on a cardiac monitor [patient] heart rate did decrease [sic] the morning but was still in the high 90s at time of discharge. ... ."

MR3 failed to reveal documented evidence of an EKG Rhythm Strip for May 26, 2019, 11-7 shift, and the two EKG Rhythm Strips that were present were not authenticated (signed, dated or timed) by the appropriate staff member.


2. Documentation from EMP3 dated August 27, 2019, revealed, "Our practice is that a strip is printed for each patient on telemetry for each shift (7, 3, 11). The strips are placed in a binder. On night shift, the patient strips are then sent to Medical Records and scanned into the EMR in the AM. ... ."

EMP3 confirmed that the EKG strips did not have signature, date and time filled out at the bottom of the page. EMP3 stated, I've questioned Nursing who states that they don't always fill out the bottom, since the date and time are on the strip. We have emailed the staff recently to notify them that the bottom portion needs filled out entirely. ... Regarding MR3 EKG Rhythm Strips, EMP responded, "... No, there were only 2 strips scanned in. ... ."