HospitalInspections.org

Based on review of facility policy and documents and interview with staff (EMP), it was determined that the facility failed to fully investigate all issues of a patient grievance for one patient (MR1)

Findings Include:

Review of facility policy "Patient Complaints" last reviewed June 22, 2017, revealed "...In the case of a Patient Grievance, a "Complaint/Grievance" form will be initiated indicating the nature of the Grievance, actions taken by Staff Members, and information obtained from the investigation..."

Review of the facility "Patient/Family Complaint Investigation" documentation on November 30, 2017, revealed concerns expressed by the complainant on September 7, 2017 that the patient was getting late doses of his medication. The complainant was concerned that the late medication was too late for the patient's seizure medication. Further review revealed a note by EMP2 stating, "...I was able to join the family meeting on September 13th to discuss the care with late medications by RN on 9/4/17. I will discuss with this RN involved in {name redacted} care..."

Review of facility medication administration record for patient medications given by PF1 revealed that PF1 currently continues to administer medications to patients late. The following was documented: On November 25, 2017 for MR16, 21 medications were documented as being given late. On November 25, 2017 for MR18, 11 medications were documented as being given late. On November November 28, 2017 for MR17, 1 medication was documented as being given late.

Interview with EMP2 on November 30, 2017, revealed "I did not talk to the nurse about lateness of medication. I primarily talked about organization." When asked by DOH if there was a way to track late medication administration, EMP2 stated, "I wasn't aware there was a report to pull out of the system."

Based on review of facility policy, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure restraints were in accordance with the order of a physician or other licensed independent practitioner for two of nineteen medical records reviewed (MR12 and MR19).

Findings include:
Penn State Health Rehabilitation Hospital was not in compliance with the following State laws:

A-0168
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)
§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under §481.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law.

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that the use of restraint was in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient for two of two MR reviewed (MR12, MR19).

This regulation was not met as evidenced by:

A review on December 1, 2017, of facility policy "Restraints" revealed "Specific Restraint Policies: Non-violent or non-self-destructive restraints...5. A physician's order is required to initiate a restraint. ...7. A written order is required daily if restraints are to be continued. ...11."

A review on December 1, 2017, at approximately 12:30PM of MR12 revealed restraints were used for 20 days beginning on September 21, 2017 and ending on October 10, 2017. Further review revealed the following:

1. September 21, 2017 restraint documentation record revealed pt was being restrained. No order for restraints noted.

2. September 25, 2017, restraint documentation record revealed patient was being restrained. No order for restraints noted.

3. September 26, 2017, restraint documentation record revealed patient was being restrained. No order for restraints noted.

4. September 30, 2017, restraint documentation record revealed patient was being restrained. No order for restraints noted.

5. October 1, 2017, restraint documentation record revealed patient was being restrained. Order for restraints noted but no "Type of Restraint" selected.

6. October 10, 2017, restraint documentation record revealed patient was being restrained. No order for restraints noted.

Interview with EMP1 on December 1, 2017, at approximately 1:30PM confirmed the above findings.


A review on December 1, 2017, at approximately 12:45PM of MR19 revealed restraints were used for 30 days beginning on August 10, 2017 and ending on September 9, 2017. Further review revealed the following:

4. August 24, 2017, restraint order is not dated, timed or signed by physician.

5. August 28, 2017, restraint order is not dated, timed or signed by physician.

6. August 29, 2017, restraint order is not dated or timed by physician.

7. August 31, 2017, restraint order is not timed by physician.

Interview with EMP1 on December 1, 2017, at approximately 1:30PM confirmed the above findings.

Based on review of medical records (MR), facility policy, and interview with staff (EMP), it was determined that medication orders were not administered according to signed orders of a practitioner for eight occurrences (MR2).

Findings include:

A review on November 30, 2017 of MR1 revealed that Lamictal, a seizure medication, was given late on the following dates and times. On August 29, 2017, the medication was scheduled for 17:00, but was not given until 18:04. On August 30, 2017, the medication was scheduled for 09:00, but was not given until 10:28. On September 3, 2017, the medication was scheduled for 09:00, but was not given until 10:14. On September 4, 2017, the medication was scheduled for 09:00, but was not given until 10:08. On September 9, 2017, the medication was scheduled for 09:00, but was not given until 10:48. On September 10, 2017, the medication was scheduled for 09:00, but was not given until 10:12. On September 11, 2017, the medication was scheduled for 09:00, but was not given until 10:29. On September 11, 2017, the medication was scheduled for 17:00, but was not given until 18:14.

A review on November 30, 2017 of facility policy, " Medication Preparation and Administration, " last reviewed June 22, 2017, revealed, " ...Timing of Medication Administration. The E-MAR system will automatically flag any medications that are administered more than 1 hour before or 1 hour after a medication is scheduled as due...When a medication time extends beyond the parameters listed below, a medication incident report will be completed and an investigation will be performed...Non-time-critical scheduled medications...Medications prescribed more frequently than daily but no more frequently than every 4 hours may be administered within 1 hour before or after the scheduled dosing time, for a total window that does not exceed 2 hours..."

Interview on November 30, 2017 at approximately 10:00 am with EMP2 confirmed that the Lamictal was administered late. "Meds should be given one hour before or after."

Based on facility policy, observation, and interview with staff (EMP), it was determined the facility failed to ensure medication were stored in a secure manner.

Findings include:


Review of facility policy "SECURITY OF MEDICATION STORAGE AREAS", last revised July, 2011 revealed "Procedure: ... 3. All medication carts shall remain locked at all times when not attended. This shall include the time required for a nurse to enter a patient's room to administer a medication."

Observation on November 1, 2017 at 3:05PM revealed a medication cart located in the hallway unattended and unlocked.

Interview on November 1, 2017 at 3:05PM with EMP1 and EMP2 confirmed (and witnessed) the medication cart was unattended and unlocked.