HospitalInspections.org

Based on review of facility documents, credential files (CF), and staff interviews, it was determined the facility failed to follow their adopted policies by failing to obtain required background checks for three of 14 Anesthesia/Emergency Department credential files reviewed. (CF15, CF16, CF22)

Findings include:

Review of the facility's policy entitled "Employment Background Checks", revised February 2015, and reviewed November 2016, revealed "... 3. External applicants undergo criminal background checks as a condition of employment. As of July 1, 2008 Penn Highlands Clearfield performs a FBI Criminal History Background Check, a Pennsylvania State Police Background Check and a Pennsylvania Child Background Check, at hire, on all employees. 4. In accordance with Act 153 requirements, as of December 31, 2014, all employees, contract staff and volunteers with a significant likelihood of regular contact with children in the form of care, guidance, supervision or training will undergo a FBI Criminal History Background Check, a Pennsylvania State Police Background Check and a Pennsylvania Child Background Check every 60 months. The areas designated as having "significant regular likelihood of regular contact with children" include but aren't limited to: Anesthesia/Operating Room/Recovery/Short Stay units, Emergency Department, Home Health, Imaging Departments, Laboratory, Patient Access/Registration, Physical, Occupational, and Speech Therapy ... ."

Review of the facilty's policy entitled "Criminal Background Check", reviewed December 2016, revealed "Policy: It is the policy of Penn Highlands Clearfield to comply with the requirements of applicable State and Federal legislation regarding employment practices. Therefore, all employees hired will be required to have a criminal history check completed ... Procedure ... New Hires. 1. Anyone who is hired after June 30, 1998 for one of the designated facilities or after January 1, 1999, will be required by the Hospital to have a criminal background check by the Pennsylvania State Police ... ."

1. Review of background check documents for CF15, CF16, and CF22 revealed that none of the three contained evidence that all three required background checks had been obtained. In addition, CF22 was noted to contain a Pennsylvania State Police Background Check which was greater than 60 months old.

2. An interview with EMP7 on August 22, 2017, confirmed the findings relative to CF15, CF16.

3. A telephone interview with EMP7 and EMP1 on August 28, 2017, confirmed the findings relative to CF22.

Based on a review of medical records (MR), facility documentation, and interview with facility staff (EMP), it was determined that Penn Highlands Clearfield failed to follow their adopted policy by failing to provide the Patient Bill of Rights to the patient or the patient's representative upon admission or thereafter, in five of five medical records (MR6, MR7, MR8, MR9 and MR10).

Findings Include:

Penn Highlands Clearfield Department/Committee: Patient Care 01.06.25 Title: Patient Bill of Rights dated May 2017 policy and procedure. "Policy: Penn Highlands Clearfield provides each patient with an explanation of his or her rights and responsibilities. It is the organizations's goal to provide medical care that encourages and respects their participation in responsible decision-making. Purpose: To provide a means to inform patients of their rights and responsibilities during the course of medical care. Procedure: The Patient's Bill of Rights and Statement of Responsibilities will be given to each patient on admission and are also available in each patient unit. Registration and/or Nursing Staff will educate the patient regarding its existence and purpose. ... Patient Rights ... 22. You have the right to be informed of your rights at the earliest possible moment in the course of your hospitalization. ... ."


1. Review of medical records MR6, MR7, MR8, MR9 and MR10 failed to reveal documented evidence that the patient was given a copy of the Patient Bill of Rights.

Interview with EMP5 on August 22, 2017, at approximately 10:00 AM revealed that the consent for treatment was signed by the patient or patient's representative on all of the above records, however, the consent does not contain verbiage regarding Patient Rights.

Based on a review of medical records (MR), facility documentation, and interview with facility staff (EMP), it was determined thatPenn Highlands Clearfield failed to follow their adopted Quality/Performance Improvement Plan to ensure that program data is analyzed, as a means to monitor the effectiveness and safety of services and quality of care, and failed to follow their adopted policy by failing to adhere to laboratory specimen results turnaround time in four of four medical records (MR11, MR12, MR13 and MR14)

Findings Include:

Penn Highlands Clearfield Department/Committee: Performance Improvement 01.06.35 Title: Quality Assessment and Performance Improvement Plan dated June 2017. "Introduction. A. Overview: The Quality Assessment and Performance Improvement Plan (QAPI) provides a framework for promoting and sustaining performance improvement at Penn Highlands Clearfield, in order to achieve excellent, safe, patient centered, cost effective care. The mission, vision, and strategic priorities for the Penn Highlands System are used to guide all improvement activities. This QAPI Plan has been designed as a mechanism to assure: a team approach is used to evaluate and improve patient care; ... patient care is objectively and systematically monitored and evaluated in relation to current standards of care; ... organization-wide education and communication of relevant performance improvement information, initiatives and outcomes; opportunities to continuously improve patient care and services are pursued, and identified problems are systematically investigated and resolved. ... B. Authority and Responsibility ... Directors and Supervisors: Directors and Supervisors are responsible for ongoing performance improvement activities in their departments. They provide support for informal performance improvement activities at the department level as well as the Hospital wide teams recommended by the BQOC [Board Quality Oversight Committee]. Many of these activities interface with other departments and the medical staff. Directors and Supervisors foster an environment of collaboration, both internally and externally with other departments. They communicate the results of performance activities with their staff. Employees: Because staff have 'expert' knowledge of the processes related to care delivery, their participation in efforts to improve patient quality and safety is essential. Staff members contribute to advancing quality and safety by: Recognizing opportunities for improvement and conveying these ideas to their director or supervisor. ... Demonstrating personal accountability by following organizational and job role policies and procedures and reporting variances which negatively impact the quality or safety of care provided ... C. Performance Improvement Models Penn Highlands Clearfield utilizes two models for Performance Improvement. The Plan, Do, Study, Act PDSA model serves as the foundation to guide all improvement activities and achieve results. ... Steps ... D ... PDSA Substeps ... Do the improvement to the process. Make the change Measure the impact of change ... D. Performance Improvement Priorities ... Priorities are based on the mission, vision and strategic plan for Penn Highlands Clearfield. ... During planning, the following are given priority consideration: ... Processes that affect a large percentage of Penn Highlands Clearfield patients Processes that place patients at risk if not performed well, if performed when not indicated or if not performed when they are indicated Processes that have been or are likely to be problem-prone ... K. Undesirable Patterns and Trends The aggregation and analysis of data may lead to the identification of undesirable patterns and trends. When this occurs, an intense analysis is performed to determine how to improve the process. An intense analysis should occur when the data comparisons show: Levels of performance, patterns or trends that vary significantly and undesirably from what was expected Performance varies significantly and undesirably from recognized standards ... ."



Penn Highlands Clearfield Department/Committee: Laboratory 52.01.01.10 Title: STAT Services and Turnaround Time, dated April 2015, policy and procedure. "Policy: Laboratory STAT Services are available to the clinician for rapid turnaround of procedures necessary for immediate treatment of the patient. The Laboratory personnel give priority to a STAT request, which utilizes increased technologists time, delays the performance and reporting of routine tests for other patients, and increases the overall costs of Laboratory services. ... The turnaround time for the collection of STAT orders will be defined as twenty (20) minutes from the time of order. Every effort will be made to meet this threshold. During periods of heavy workload, these times may be exceeded as multiple STAT orders may require prioritization. The ordering department will be notified by the collector if this time cannot be met. STAT results on out-patients are phoned or faxed immediately after completion of all STAT tests ordered on an individual. ... During periods of heavy workloads, the turnaround time may exceed the listed maximum time. Since STAT orders may be received from several physicians at the same time, the Laboratory will perform the STAT tests according to the STAT priority list. This may cause a delay in turnaround time of other STAT orders. ... Procedure: The turnaround time listed below is the maximum time for the reporting of STAT results. STAT results can be available before the times listed. The Laboratory recognizes the urgency of these orders and will make every effort to complete the tests as soon as possible. STAT Laboratory results are available 24 hours a day, 7 days a week. ... A. Results available within 30 minutes: ... Troponin I ... E. Priorities for STAT testing: In the event of multiple STAT orders arriving in the Laboratory at the same time, the Laboratory will perform these tests according to the following priorities: 1. Hemorrhage ... 2. This group of tests should take priority based on the condition of the individual patients. Professional judgement by the technologist should be used in setting priorities for any given situation. 1. Transfusion reaction 2. Spinal Fluid Analysis 3. Pregnancy test-ED patient 4. Glucose 5. Blood Culture Collection 6. CBC 7. Electrolytes 8. Acetone, plasma 9. Urinalysis ... ."


1. Facility Quality Dashboard documentation related to Emergency Department Stat turnaround time for Troponin-I goal less than 60 minutes, dated July 2016, through June 2017, revealed a benchmark of 100% and an average year to date percentage of 66%.

Interview with EMP6 confirmed the above findings.


2. A telephone interview was conducted with EMP1 on August 24, 2017, at 2:45 PM. "There has been nothing in Quality minutes related to Troponins. That has not happened. The dashboard goes to Penn Highlands, it does not come here."


3. Review of facility documentation entitled "CLFD ED Stat TAT Report" dated August 20, 2017, from 9:20 AM through August 20, 2017, until 11:13 PM, revealed a total of 13 Stat Troponin-I levels were drawn in the Emergency Department. Four of the 13 levels (MR11, MR12, MR13, MR14, revealed, "Average Actual TAT Requested Collection to Completed" time of greater than 60 minutes.


4. Additional facility documentation provided by EMP6 revealed, MR11 Stat Troponin-I was collected at 12:41 PM, received in the Lab at 12:48 and result verified at 1:46 PM (one hour and five minutes from collection to resulted); MR12 Stat Troponin-I was collected at 12:14 PM, received in the Lab at 12:49 PM and result verified at 1:52 PM (one hour and 38 minutes from collection to resulted); MR13 Stat Troponin-I was collected at 3:42 PM, received in the Lab at 3:46 PM, and result verified at 4:30 PM (48 minutes from collection to resulted); MR14 Stat Troponin-I was collected at 5:30 PM, received in the Lab at 5:35 PM and resulted at 6:54 PM (one hour and 24 minutes from collection to resulted).

Interview with EMP6 confirmed the above findings.


Cross Reference:
482.27(a)(1) Emergency Laboratory Services must be available 24 hours a day

Based on a review of facility documents, Credential Files (CF), Medical Records (MR), and staff interviews (EMP), it was determined that Penn Highlands Clearfield failed to follow adopted Medical Staff Bylaws and their adopted Admission Policy, by failing to ensure Admission orders were written by a physician, for two of two medical records reviewed (MR37, MR38), by failing to adopt a policy that is consistent with the Medical Staff Bylaws/Rules and Regulations and the facility's adopted Admission and Transfer policies, and by failing to follow adopted Medical Staff Bylaws, by failing to ensure that language in the Penn Highlands Clearfield Nurse Practitioner Collaborative Agreement and Prescriptive Authority Agreement Document, reflected the Bylaws requirement that the CRNP (Certified Registered Nurse Practitioner) activities are under the direct and immediate supervision of the supervising physician, and that at all times the employing or supervising physician will remain responsible for all acts of the CRNP.


Findings include:


Medical Staff Bylaws of Penn Highlands Clearfield, dated March 28, 2016. "... Article IV-Part A: Allied Health Professionals and Licensed Dependent Practitioners: Categories of health care professionals approved by the Board who are licensed or certified by their respective licensing service agencies, and who provide services under the supervision of physicians who are presently appointed to the medical staff are eligible to practice as Allied Health Professionals. The following categories of Licensed Dependent Allied Health Professionals are permitted to exercise clinical duties at Penn Highlands Clearfield: 1. Certified Physician Assistants 2. Certified Registered Nurse Practitioners. Certified Physician Assistants and Certified Registered Nurse Practitioners will be processed through the medical staff credentialing processes and shall be classified as Licensed Dependent Allied Health Professionals. The Allied Health Professional must provide the hospital a copy of the collaborative written agreement approved by the state as part of the application process. Allied Health Professionals must apply for hospital clinical responsibilities jointly with the medical staff practitioner who is designated as the supervisor. The application procedures for Dependent Allied Health Professionals shall be the same as those specified for an applicant to the Medical Staff and shall follow the Medical Staff Bylaws and Rules and Regulations as they apply to admission to the Medical Staff including the provisional period. The application shall include a list of specific clinical responsibilities requested by the Allied Health Professional which shall be consistent with the privileges granted to all proposed supervising practitioners. The clinical activities of the Allied Health Professional shall not exceed the clinical privileges granted to the supervising practitioner and shall not exceed the scope of practice allowed by the appropriate state licensing board for the individual Allied Health Professional. A listing of all supervising practitioners shall be included in the application process. A listing of the Allied Health Professional's scope of clinical activities, along with the written agreement, will be readily available to hospital staff. Allied Health Professionals shall function at all times under the direction and supervision of a supervising practitioner. The role of the supervising practitioner shall include assurance that all activities of the Allied Health Professional are conducted within the scope of clinical responsibilities specifically granted to the Allied Health Professional ... Any activities permitted by the Board to be done in the hospital by an Allied Health Professional shall be done only under the direct and immediate supervision of his/her employer or supervising physician. At all times the employing or supervising physician will remain responsible for all acts of any of the Allied Health Professionals within the hospital ... Allied Health Professionals granted responsibilities will participate only in the care of patients admitted to the service of the supervising practitioner or patient's seen as a result of a consultation by supervising practitioners ... ."


Penn Highlands Clearfield Medical Staff Rules & Regulations, dated June 27, 2016. "... Article I. Admission. Section 1: Who May Admit Patients. A patient may be admitted to the hospital only by physicians who have been appointed to the staff and who have privileges to do so. Patients shall be admitted for the treatment of any and all conditions and diseases for which the hospital has facilities and personnel ... Section 2: Admitting Physician's Responsibilities. Each patient shall be the responsibility of a designated appointee to the Medical Staff. In the case of a group practice, unless the admission sheet clearly shows the admitting physician, the first name listed on the admission sheet in any group practice description shall be considered the responsible, designated Medical Staff appointee. Such appointee shall be responsible for the medical care and treatment, including daily rounds on the patient and documented findings in a daily progress note, for the prompt completeness and accuracy of the medical record, for necessary special instructions, and for transmitting reports of the condition of the patient to the referring appointee and to relative of the patient ... Section 4: Admission Office Procedure (a) An order for an elective or routine admission must be made by the attending physician and presented to the admitting office before the time the patient presents himself/herself for admission ... Article II Medical Orders ... Section 2: Who May Write Orders (a) Medical Staff appointees, Medical Associates, and Allied Health Professionals shall have the authority to write orders and only as permitted by their clinical privileges or scope of practice ... Article X Discharge Section 1: Who May Discharge. Patients shall be discharged only on an order of the attending physician. Should a patient leave the hospital against the advice of the attending physician, or without proper discharge, a notation of the incident shall be made in the patient's medical record, and the patient shall be asked to sign the hospital release form ... ."


Penn Highlands Clearfield Medical Staff Rules & Regulations, dated February 27, 2017. "... Article II. Medical Orders ... Section 2: Who May Write Orders (a) Medical Staff appointees, Medical Associates, and Allied Health Professionals shall have the authority to write orders and only as permitted by their clinical privileges or scope of practice ... ."


Penn Highlands Clearfield Admission Policy, review dated of July 2017. "Policy: It is the policy of Penn Highlands Clearfield to admit patient by the order of a member of the Hospital's Medical Staff. Procedure: Upon the order of a member of the Medical Staff, a patient will be admitted to the hospital ... ."


Penn Highlands Clearfield Exam, Treatment, Transfer for Emergencies and Women in Labor, reviewed July 2017. "... In the event and unstable individual must be transferred, the hospital will provide treatment to minimize the risk of transfer. The physician arranging the transfer must identify the individual (or the person responsible for the individual) the risks and benefits of the transfer and certify the need for transfer. A consent to or refusal of transfer must be properly signed and witnessed on the approved Consent for Transfer Form ... ."


1. Review of Penn Highlands Clearfield Medical Staff Policy Physician Assistant/Nurse Practitioner and Physician Supervisor Responsibilities and Limitations, approved by Medical Executive Committee February 21, 2017 and Board of Director February 27, 2017. "Purpose: To describe the approved activities, responsibilities and limitations of physician assistants (PA-C) nurse practitioners (CRNP), and supervising/employing physicians in order to facilitate patient safety, staff competence and proficiency, internal communication and regulatory compliance. Approved Activities, Responsibilities and Limitations ... This policy does not supersede any other policies or rules/regulations governing physician assistant or nurse practitioner activities in the hospital. Permitted Activities of Physician Assistant/Nurse Practitioner ... admit, discharge, and/or transfer a patient, when working in conjunction with a medical staff physician ... ."


2. A review of MR 37 revealed an order which stated, "Register patient: ... Order Date/Time: 7/25/2017, 23:24 EDT... Ordering Physician: (EMP9) CRNP ... Order Details: 7/25/17, 11:24:00PM EDT, Inpatient, ECU Order Comment: Based on clinical conditions documented throughout the medical record, I certify the medical necessity of this inpatient admission and estimate a two midnight length of stay or longer."

Surveyor requested documentation of cosignature of physician. Surveyor was provided with documentation which stated that order was automatically discontinued on 07/27/17 at 16:03 due to discharge. The documentation also stated that this order was electronically signed by the physician on 07/31/17 at 16:31 EDT.


A review of MR38 revealed an order which stated "Register patient: ... Order Date/Time: 7/20/2017, 21:42 EDT ... Ordering Physician: (EMP9) CRNP ... Order Details: 7/20/17, 9:42 PM EDT, Inpatient, 2nd Floor Order Comment: Based on the clinical conditions documented throughout the medical record, I certify the medical necessity of this inpatient admission and estimate a two midnight length of stay or longer."

Surveyor requested documentation of cosignature of physician. Surveyor was provided with documentation which stated that order was automatically discontinued on 07/26/17 at 19:01 EDT due to discharge. The documentation also stated that this order was electronically signed by the physician on 07/21/17 at 07:55 EDT.

An interview with EMP1 on August 23, 2017, confirmed that the above orders are admission orders and that these orders were written by the CRNP and were not verbal orders obtained by the CRNP from the physician.



3. A review of the Credential File for EMP9 (CF1) was completed. A review of the Clinical Privileges relative to this file revealed that admitting, discharging and/or transferring patients was not included in the approved privileges. In addition, the Penn Highlands Clearfield Nurse Practitioner Collaborative Agreement and Prescriptive Authority Agreement was reviewed and did not include admitting, discharging and/or transferring patients. It was also noted that this document included the following statement, "... In the absence of the collaborating physician, any other PHC physician may be used for consultation ... ."



4. Interview with EMP1 and EMP8 on August 23, 2017, revealed that the above policy is inconsistent with the Medical Staff Bylaws/rules and regs, and/or the hospital's admission policy.

Based on a review of medical records (MR), facility documentation, and interview with facility staff (EMP), it was determined that Penn Highlands Clearfield failed to follow their adopted policy by failing to adhere to Laboratory specimen results turnaround time in four of four medical records (MR11, MR12, MR13 and MR14) and failed to follow their adopted Quality/Performance Improvement Plan by failing to analyze undesirable outcomes.

Findings Include:

Penn Highlands Clearfield Department/Committee: Laboratory 52.01.01.10 Title STAT Services and Turnaround Time dated April 2015, policy and procedure. "Policy: Laboratory STAT Services are available to the clinician for rapid turnaround of procedures necessary for immediate treatment of the patient. The Laboratory personnel give priority to a STAT request, which utilizes increased technologists time, delays the performance and reporting of routine tests for other patients, and increases the overall costs of Laboratory services. ... The turnaround time for the collection of STAT orders will be defined as twenty (20) minutes from the time of order. Every effort will be made to meet this threshold. During periods of heavy workload, these times may be exceeded as multiple STAT orders may require prioritization. The ordering department will be notified by the collector if this time cannot be met. STAT results on out-patients are phoned or faxed immediately after completion of all STAT tests ordered on an individual. ... During periods of heavy workloads, the turnaround time may exceed the listed maximum time. Since STAT orders may be received from several physicians at the same time, the Laboratory will perform the STAT tests according to the STAT priority list. This may cause a delay in turnaround time of other STAT orders. ... Procedure: The turnaround time listed below is the maximum time for the reporting of STAT results. STAT results can be available before the times listed. The Laboratory recognizes the urgency of these orders and will make every effort to complete the tests as soon as possible. STAT Laboratory results are available 24 hours a day, 7 days a week. ... A. Results available within 30 minutes: ... Troponin I ... E. Priorities for STAT testing: In the event of multiple STAT orders arriving in the Laboratory at the same time, the Laboratory will perform these tests according to the following priorities: 1. Hemorrhage ... 2. This group of tests should take priority based on the condition of the individual patients. Professional judgement by the technologist should be used in setting priorities for any given situation. 1. Transfusion reaction 2. Spinal Fluid Analysis 3. Pregnancy test-ED patient 4. Glucose 5. Blood Culture Collection 6. CBC 7. Electrolytes 8. Acetone, plasma 9. Urinalysis ... ."


Penn Highlands Clearfield Department/Committee: Performance Improvement 01.06.35 Title: Quality Assessment and Performance Improvement Plan dated June 2017. "Introduction A. Overview The Quality Assessment and Performance Improvement Plan (QAPI) provides a framework for promoting and sustaining performance improvement at Penn Highlands Clearfield, in order to achieve excellent, safe, patient centered, cost effective care. The mission, vision, and strategic priorities for the Penn Highlands System are used to guide all improvement activities. This QAPI Plan has been designed as a mechanism to assure: a team approach is used to evaluate and improve patient care; ... patient care is objectively and systematically monitored and evaluated in relation to current standards of care; ... organization-wide education and communication of relevant performance improvement information, initiatives and outcomes; opportunities to continuously improve patient care and services are pursued, and identified problems are systematically investigated and resolved. ... B. Authority and Responsibility ... Directors and Supervisors: Directors and Supervisors are responsible for ongoing performance improvement activities in their departments. They provide support for informal performance improvement activities at the department level as well as the Hospital wide teams recommended by the BQOC [Board Quality Oversight Committee]. Many of these activities interface with other departments and the medical staff. Directors and Supervisors foster an environment of collaboration, both internally and externally with other departments. They communicate the results of performance activities with their staff. Employees: Because staff have 'expert' knowledge of the processes related to care delivery, their participation in efforts to improve patient quality and safety is essential. Staff members contribute to advancing quality and safety by: Recognizing opportunities for improvement and conveying these ideas to their director or supervisor. ... Demonstrating personal accountability by following organizational and job role policies and procedures and reporting variances which negatively impact the quality or safety of care provided ... C. Performance Improvement Models Penn Highlands Clearfield utilizes two models for Performance Improvement. The Plan, Do, Study, Act PDSA model serves as the foundation to guide all improvement activities and achieve results. ... Steps ... D ... PDSA Substeps ... Do the improvement to the process. Make the change Measure the impact of change ... D. Performance Improvement Priorities ... Priorities are based on the mission, vision and strategic plan for Penn Highlands Clearfield. ... During planning, the following are given priority consideration: ... Processes that affect a large percentage of Penn Highlands Clearfield patients Processes that place patients at risk if not performed well, if performed when not indicated or if not performed when they are indicated Processes that have been or are likely to be problem-prone ... K. Undesirable Patterns and Trends The aggregation and analysis of data may lead to the identification of undesirable patterns and trends. When this occurs, an intense analysis is performed to determine how to improve the process. An intense analysis should occur when the data comparisons show: Levels of performance, patterns or trends that vary significantly and undesirably from what was expected Performance varies significantly and undesirably from recognized standards ... ."


1. Review of facility documentation entitled, "CLFD ED Stat TAT Report" dated August 20, 2017, from 9:20 AM through August 20, 2017, until 11:13 PM revealed a total of 13 Stat Troponin-I levels drawn in the Emergency Department. Four of the 13 levels (MR11, MR12, MR13, MR14, revealed, "Average Actual TAT Requested Collection to Completed" time of greater than 60 minutes.


2. Additional facility documentation provided by EMP6 revealed, MR11 Stat Troponin-I was collected at 12:41 PM, received in the Lab at 12:48 and result verified at 1:46 PM (one hour and five minutes from collection to resulted); MR12 Stat Troponin-I was collected at 12:14 PM, received in the Lab at 12:49 PM and result verified at 1:52 PM (one hour and 38 minutes from collection to resulted); MR13 Stat Troponin-I was collected at 3:42 PM, received in the Lab at 3:46 PM, and result verified at 4:30 PM (48 minutes from collection to resulted); MR14 Stat Troponin-I was collected at 5:30 PM, received in the Lab at 5:35 PM and resulted at 6:54 PM (one hour and 24 minutes from collection to resulted).

Interview with EMP6 confirmed the above findings.


3. Facility Quality Dashboard documentation related to Emergency Department Stat turnaround time for Troponin-I goal less than 60 minutes, dated July 2016, through June 2017, revealed a benchmark of 100% and an average year to date percentage of 66%.

Interview with EMP6 confirmed the above findings.


4. A telephone interview was conducted with EMP1 on August 24, 2017, at 2:45 PM. " There has been nothing in Quality minutes related to Troponins. That has not happened. The dashboard goes to Penn Highlands, it does not come here."



Cross Reference:
482.21(a) Standard: Program Data

Based on a review of facilty documents, and staff interviews (EMP), it was determined that Penn Highlands Clearfield failed to adopt policies which defined procedure requirements and expectations for psychiatric patients requiring close/constant observation in the Emergency Department, and staff failed to follow their adopted policy to obtain patient consent to transfer in two of 10 medical records. (MR22, MR27)

Findings:


Penn Highlands Clearfield Emergency Department Policy/Procedure Manual revealed no documented evidence of a policy/procedure defining close/constant observation.


Penn Highlands Clearfield Department/Committee: Nursing, August 2017. "Policy: It is the policy of the Penn Highlands Clearfield to provide safe and effective care to the patient who is at risk for suicide. Purpose: To outline the nursing care and management of patients in a hospital environment who have attempted harm or are threatening/at risk for attempting harm to themselves. ... 3. Initiate the 1-1 Observation Check Sheet. ... ."


Penn Highlands Clearfield Department/Committee Patient Care Title: Exam, Treatment, Transfer For Emergencies and Women in Labor, July 2017. "Policy: To assure all patients presenting to the Emergency Department with an emergency condition are medically screened an appropriately transferred when indicated. ... The Physician arranging the transfer must identify to the individual (or the person responsible for the individual) the risks and benefits of the transfer and certify the need for the transfer. A consent to or refusal of transfer must be properly signed and witnessed on the approved Consent For Transfer Form. ... ."

Emergency Department Policy, August 2016, " ... D. Transfer Packet. Transfer information is to be completed in a timely manner. 1. Physician transfer forms are completed by the physician and signed by customer/family."


1. MR22 dated August 20, 2017, revealed, "... Orders Information ... 08/20/17, 23:57 ... Staff to Watch for Patient Safety ... Ordered ... 08/20/2017, 23:57 Face to Face ... Ordered ... ."


2. Penn Highlands Clearfield Security Patient Behavioral Report, dated August 20, 2017. "... 5. Documentation of Time Spent with Patient in 15 min Intervals ... 150 Patient is laying down and I am back from rounds ... ."

Interview with EMP5 on August 22, 2017, revealed that the verbiage "Staff to Watch for Patient Safety" is actually the order for a one to one."

Interview with EMP3 on August 22, 2017, at approximately 1:45 PM revealed "We do not have a policy to address one to one in the Emergency Department."


3. Review of MR27 dated August 16, 2017, revealed patient was transferred from Clearfield Emergency Department to another facility. MR27 did not contain documentation that the patient/family signed a consent to transfer.


4. Review of MR22 dated August 21, 2017, revealed patient was transferred from Clearfield Emergency Department to another facility. MR22 did not contain documentation that the patient/family signed a consent to transfer.


EMP1 on August 22, 2017, at approximately 11:00 AM confirmed that there was no documented evidence in MR22 and MR27 that patient/family signed a consent to transfer.


Interview with EMP2 on August 22, 2017, at approximately 11:00 AM confirmed the above findings. "We do not get patient/family signatures for consent to transfer. ... It's a verbal conversation between the physician and patient and or family."