HospitalInspections.org

The Condition for Physical Environment is not met based on the results of the Department of Health, Division of Safety Inspection survey completed on February 9, 2017. See the Life Safety Code 2567 for the deficiencies.

Based on review of facility documents, personnel files (PF) and staff interview (EMP), it was determined the facility failed to ensure facility staff who have the potential to come into contact with children on a regular basis have the FBI Fingerprint check clearance completed as per facility directive for three of 17 personnel files reviewed (PF7, PF12 and PF13) and for 117 of 117 outstanding staff FBI Fingerprint check clearances reviewed (OTH1 through OTH117).

Findings include:

Review on March 1, 2017, of the facility's Security Services directive dated December 21, 2015, revealed "Due to the changes from Pennsylvania Act 153, Schuylkill Health Employees who have the potential to come into contact with children on a regular basis are required to have the following clearances done every 5 years. 1. PA Criminal Background Check: Check is completed online by the medical center and submitted to the state. If no record is found the result will be recorded in your personnel file. If a record is found the form will be mailed to your residence and you are required to bring the clearance form to the Human Resource Department in a timely manner. Complete attached form and forward to Human Resources. 2. FBI Fingerprint check: Employee will be registered to complete this task with [name of company] by the Human Resources Department. [Name of company] locations can be found at [web site link] Clearance will be mailed to your residence and you are required to bring the original clearance to the Human Resource Department in a timely manner. 3. PA Child Abuse History Clearance: Employee will complete the Department of Public Welfare PA Child Abuse History Clearance application. Employee can hand write or use a printable form [name of web site] ... Clearance will be mailed to your residence in 6 - 8 weeks and you are required to bring the original clearance to the Human Resource Department in a timely manner. ..."

1) Review of PF7 on March 1, 2017, revealed the employee was hired June 1996. PF7 did not contain a PA Child Abuse History Clearance or FBI Fingerprint check.

Review of PF12 on March 1, 2017, revealed the employee was hired February 1997. PF12 did not contain the FBI Fingerprint check.

Review of PF13 on March 1, 2017, revealed the employee was hired March 2013. PF13 did not contain the FBI Fingerprint check.

Interview with EMP3 on March 1, 2017, at approximately 9:45 AM confirmed PF7, PF12 and PF13 did not contain the required clearances. EMP3 confirmed these employees had the potential to come into contact with children on a regular basis.

2) Review on March 1, 2017, of the facility's Act 153 Background check report provided by EMP3 revealed OTH1 through OTH117 did not return their FBI Fingerprint checks to the facility as required by the facility.

Interview with EMP3 on March 1, 2017, at approximately 11:15 AM confirmed OTH1 through OTH117 had the potential to come into contact with children on a regular basis. EMP3 revealed OTH1 and OTH117 were employees hired between 1982 and 2015. EMP3 revealed these employees were notified over one-year ago of the facility's requirement to obtain an FBI fingerprint check.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure staff witnessing patient signatures dated and signed their signatures for six out of seven medical records from the Emergency Department (MR24, MR26, MR27, MR28, MR29 and MR30).

Findings include:

Review on February 27, 2017 of facility "Medical Record Management" policy, last reviewed January 2016, revealed "Purpose ...Medical Records are created in the Registration Department and are accessible via [name of system] to authorized users to electronically document the treatment and continuum of patient care. Documentation In The Medical Record The following practitioners/allied health professionals/employees may document in the Medical Record at Schuylkill Medical Center, East Norwegian Street: ... 7. Clinical Secretaries (employed by the Medical Center) ... Policy ... 6. All entries in the medical record are dated, timed, and authenticated by the author. ... " .

Review on February 27, 2017 of the facility's form "Authorization for Treatment Consent," revealed a form with several paragraphs which included information for "Authorization for Hospital Treatment, Assignment of Insurance Benefits: ... Statement to Permit Payment of Medicare Benefits to Provider, Physicians and Patient: ... Financial Responsibility: ..." At the bottom of the form there were areas for signatures. One area was to be signed by the individual providing the consent, with date, time and relationship and the signature of the witness, with the date, time completed.

Review on February 27, 2017, of MR24 revealed an "Authorization For Treatment Consent" form. There was no documentation of the date and time staff witnessed the patient's signature.

Interview with EMP9 on February 27, 2017, at approximately 2:25 PM, of MR24 confirmed an "Authorization For Treatment Consent" form. There was no documentation of the date and time staff witnessed the patient's signature.

Review on February 27, 2017, of MR26 revealed an "Authorization For Treatment Consent" form. There was no documentation of the date and time staff witnessed the patient's signature.

Interview with EMP9 on February 27, 2017, at approximately 2:25 PM, of MR26 confirmed an "Authorization For Treatment Consent" form. There was no documentation of the date and time staff witnessed the patient's signature.

Review on February 27, 2017, of MR27 revealed an "Authorization For Treatment Consent" form. There was no documentation of the date and time staff witnessed the patient's signature.

Interview with EMP9 on February 27, 2017, at approximately 2:25 PM, of MR27 confirmed an "Authorization For Treatment Consent" form. There was no documentation of the date and time staff witnessed the patient's signature.

Review on February 27, 2017, of MR28 revealed an "Authorization For Treatment Consent" form. There was no documentation of the date and time staff witnessed the patient's signature.

Interview with EMP9 on February 27, 2017, at approximately 2:25 PM, of MR28 confirmed an "Authorization For Treatment Consent" form. There was no documentation of the date and time staff witnessed the patient's signature.

Review on February 27, 2017, of MR29 revealed an "Authorization For Treatment Consent" form. There was no documentation of the date and time staff witnessed the patient's signature.

Interview with EMP9 on February 27, 2017, at approximately 2:25 PM, of MR29 confirmed an "Authorization For Treatment Consent" form. There was no documentation of the date and time staff witnessed the patient's signature.

Review on February 27, 2017, of MR30 revealed an "Authorization For Treatment Consent" form. There was no documentation of the date and time staff witnessed the patient's signature.

Interview with EMP9 on February 27, 2017, at approximately 2:25 PM, of MR30 confirmed an "Authorization For Treatment Consent" form. There was no documentation of the date and time staff witnessed the patient's signature.

Based on a review of facility documentation, medical records (MR) and staff interview (EMP), it was determined the facility failed to document the date and time the physician cosigned telephone orders for two of five restraint orders reviewed (MR11 and MR12).

Findings include:

Review on March 1, 2017 of facility policy "Computerized Telephone/Verbal Orders," last reviewed May 2016, revealed "Policy: Computerized telephone/verbal order entry is permissible in designated Computerized Provider Order Entry (CPOE) Units. All providers should enter orders themselves using Computerized Order Entry whenever possible. The use of telephone/verbal orders should be limited to urgent circumstances in which it is impossible or impractical for the provider to write the order or enter it into the computer. Procedure: 1. Security will be given to Registered Nurses who work on Units designated to use computerized verbal/telephone order entry. 2. When the telephone and/or verbal order is received, the order will be entered directly into the computer system. A paper worksheet may be used and discarded upon order entry and verification in the computer system. A paper worksheet may be used and discarded upon order entry and verification in the computer system if unable to access the computer at the time of the receipt of the order. The orders must be entered by the person receiving the order as soon as computer access is available. ... 13. The provider will access their telephone verbal orders and those orders requiring co-signature via the [name of charting system] and the E-sign Application. E-sign will be entered to electronically sign/co-sign the telephone/verbal orders. The computer system will date and time stamp the signature. Verbal and/or telephone orders must be signed, dated and timed within 24 hours. ... "

Review on March 1, 2017 of facility policy "Medical Record Management," last reviewed January 2016, revealed "Purpose: To ensure that Medical Staff Members, when acting as the attending practitioner of a patient, are responsible for the preparation of a complete and legible electronic medical record for each patient. ... 9. All clinical entries in the patient's medical record will be legible and accurately dated, timed, and authenticated. Rubber stamps are not considered acceptable. ... 16. Telephone orders shall be signed, dated, and timed within twenty four (24) hours of being given. ..."

Review of MR11 on February 28, 2017, at approximately 11:00 AM, revealed MR11 was admitted to the Intensive Care Unit on January 12, 2016. A telephone order for bedrails for safety was written at 12:50 PM on January 13, 2016. The physician signature for this telephone order was not dated or timed.

Review of MR12 on February 28, 2017, at approximately 11:00 AM, revealed MR12 was admitted to the Intensive Care Unit on January 30, 2017. A telephone order for bedrails for safety was written at 4:00 PM on January 30, 2017. The physician signature for this telephone order was not dated or timed.

Interview with EMP2 at approximately 10:30 AM on March 1, 2017, confirmed MR11 and MR12 had telephone orders for bedrails. EMP2 also confirmed the physician signatures for these telephone orders were not dated or timed.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure medications brought to the hospital by patients on admission were returned to the patients upon discharge for 11 of 37 discharged medical records reviewed (MR34, MR35, MR37, MR38, MR39, MR40, MR41, MR42, MR43, MR43 and MR45).

Findings include:

Review on February 28, 2017, of the facility's "Drugs Brought Into Medical Center By Patients" policy, last reviewed June 2016, revealed "Policy All drugs brought into the Medical Center by patients for medication administration, shall only be administered following an authorized prescriber's order, and proper identification by the Medical Center pharmacist. This practice will be discouraged except for unusual circumstances. Procedure All medication-administering personnel will, prior to giving any drugs brought into the Medical Center by patients: ... 5. Nursing will inventory all medications brought in by a patient whether to be used or not and forward a copy of inventory to pharmacy. The pharmacy will verify this inventory and store appropriately. A log will be maintained of all medications received. ... 7. Upon discharge, the remainder of the medication will be returned to the patient, except controlled substances which will require physician authorization prior to being returned. ... 9. Any medication not returned to the patient will be disposed of appropriately, witnessed and documented."

Observation of the pharmacy's locked controlled medication cabinet on February 28, 2017, revealed orange bottles with white lids. These orange bottles contained medications.

Interview with EMP4 on February 28, 2017, at approximately 10:45 AM revealed the orange bottles contained bottles of medications brought in by patients when admitted. EMP4 confirmed the patients were now discharged.

Review of MR34's medication bottles on February 28, 2017, revealed the following: 12 tablets of Vitamin B 100 milligram (mg); 80 tablets of Lasix 80 mg; 30 tablets of Allopurinol (a blood pressure medication) 100 mg; 30 tablets of Allopurinol 300 mg and 30 tablets of Lasix 80 mg.

Review of MR35's medication bottles on February 28, 2017, revealed the following: 7 tablets of Tramadol HCL (a narcotic pain medication) 50 mg; 5 tablets of Lasix 40 mg; 18 tablets of Januvia (a diabetic medication) 100 mg; 26 tablets of Nexium (a medication to treat stomach conditions) 40 mg; 85 tablets of Glypride (a diabetic medication) 10 mg; 23 tablets of Prednisone (a steroid medication) 10 mg and 3 tablets of Levaquin (an antibiotic) 500 mg.

Review of MR37's medication bottle on February 28, 2017, revealed the following: 120 tablets of Oxycodone HCL (a narcotic medication) 10 mg. and a second medication bottle containing 14 tablets of Oxycodone HCL 10 mg.

Review of MR38's medication bottle on February 28, 2017, revealed the following: 52 tablets of Lorazepam (an anti-anxiety medication) 0.5 mg.

Review of MR39's medication bottle on February 28, 2017, revealed the following: 114 tablets of Diazepam (an anti-anxiety medication) 10 mg.

Review of MR40's medication bottle on February 28, 2017, revealed the following: 2 tablets of Hydromorphone (a narcotic medication) 2 mg.

Review of MR41's medication bottle on February 28, 2017, revealed the following: 27 tablets of Oxycodone HCL 5 mg.

Review of MR42's medication bottle on February 28, 2017, revealed the following: 15 tablets of Hydrocodone-Acetaminophen (a narcotic medication) 5/300 mg.

Review of MR43's medication bottle on February 28, 2017, revealed the following: 4 tablets of Hydrocodone-Acetaminophen 5/325 mg.

Review of MR44's medication bottle on February 28, 2017, revealed the following: 89 tablets of Lorazepam 0.5 mg.

Review of MR45's medication bottle on February 28, 2017, revealed the following: 8 tablets of Oxycodone HCL 10 mg.

Interview with EMP4 and EMP5 on February 28, 2017, at approximately 11:20 AM confirmed MR34, MR35, MR37, MR38, MR39, MR40, MR41, MR42, MR43, MR43 and MR45 brought medications into the hospital when admitted, and the medications were not returned to MR37, MR38, MR39, MR40, MR41, MR42, MR43, MR43 and MR45 upon discharge, EMP4 and EMP5 confirmed there was no documentation the patients' physicians were contacted to provide authorization to release the medications prior to the patients being discharged.

Based on observation and staff interview (EMP), it was determined the facility failed to ensure intravenous solutions were used for only one patient.

Findings include:

A request was made of EMP6 and EMP7 on February 27, 2017, for a facility policy, procedure or guideline for facility staff to follow regarding discarding of intravenous solutions following single patient use. No policy was provided.

Observation on February 27, 2017, of the facility's Computed Tomography (CT) scan room revealed a 1-liter bag of normal saline and a 500-milliliter bottle of CT contrast solution hanging from an intravenous (IV) pole.

Interview with EMP6 and EMP7 on February 27, 2017, at approximately 11:00 AM revealed CT staff connect tubing from the CT injectors to the normal saline and the CT contrast solution. The injectors draw a predetermined amount of solution from the bag of normal saline and the CT contrast solution. These solutions were then injected into the patient at specific time intervals. EMP6 revealed the 1-liter bag of normal saline and the 500-milliliter bottle of CT contrast solutions were used for multiple patients over a six hour period.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to document the type of skin preparation used to prepare the surgical area for five of five interventional radiology medical records reviewed (MR1, MR2, MR31, MR32 and MR33), and the facility failed to document the alcohol skin preparation solutions were completely dry prior to draping the patient for five of five interventional radiology medical records reviewed (MR1, MR2, MR31, MR32 and MR33).

Findings include:

1) Interview with EMP6 on February 27, 2017, at approximately 9:45 AM revealed the facility uses a non-flammable Betadine surgical skin preparation (prep) and a flammable Chlorhexidine Gluconate surgical skin prep.

Review of MR1 on February 27, 2017, revealed the patient was admitted to interventional radiology (IR) on February 27, 2017, for an ultrasound-guided fine needle biopsy (a sterile surgical procedure to obtain a tissue sample) of the thyroid. There was no documentation in MR1 indicating what type of skin prep the facility used.

Review of MR2 on February 27, 2017, revealed the patient was admitted to IR on January 20, 2017, for an IR angiogram (a sterile surgical procedure to detect blockage of the blood vessel). There was no documentation in MR2 indicating what type of skin prep the facility used.

Review of MR31 on February 27, 2017, revealed the patient was admitted to IR on February 6, 2017, for placement of a ureteral stent (a sterile surgical procedure to place a tube into the tube coming from the kidney). There was no documentation in MR31 indicating what type of skin prep the facility used.

Review of MR32 on February 27, 2017, revealed the patient was admitted to IR on January 24, 2017, for an IR angiogram. There was no documentation in MR32 indicating what type of skin prep the facility used.

Review of MR33 on February 27, 2017, revealed the patient was admitted to IR on January 31, 2017, for an IR angiogram. There was no documentation in MR33 indicating what type of skin prep the facility used.

Interview with EMP6 on February 27, 2017, at approximately 10:20 AM confirmed MR1, MR2, MR31, MR32 and MR33 had surgical procedures completed in IR, and there was no documentation in the patients' medical records indicating what type of skin prep the facility used.

2) Review on February 27, 2017, of the facility's "Use of Alcohol Based Skin Prep" policy, last reviewed December 2016, revealed, "Purpose: To educate surgical staff to risk reduction techniques to permit sage [sic] use of alcohol-based skin preparations. To reduce the risk of surgical fires. ..."

Review on February 27, 2017, of the facility's "Proposed Changes to Skin Prep, Preoperative System-Wide Policy [and] Procedure," no review date, revealed "A. Specific Guidelines Unique to Using 2% Chlorhexidine Gluconate and 70% Isopropyl Alcohol (provided in its own special applicator) as a prepping agent. 1. The circulating nurse should select the appropriate size sterile package of prepping solution / applicator, keeping in mind the size and location of the area to be prepped. ... 2. The circulation nurse should be aware of the flammable properties and related issues associated with using this prepping solution. a. Extreme care should be taken to prevent any pooling of prep solution, in order to prevent skin irritation or a potential source of flammability (due to the high alcohol content). (1) Prior to beginning the prep, absorbent prep pads must be placed underneath any body areas where the solution could potentially pool or saturate clothing or bedding. (2) A plastic steri-drape barrier must be placed around any tourniquet used for extremity procedures, prior to beginning the prep, in order to prevent the solution from pooling underneath the tourniquet. (3) Any material (bedding, clothing, tourniquet under wrap, etc.) that becomes saturated with the prepping solution must be removed from the surgical field prior to applying any sterile draping materials or beginning the surgical procedure - especially if the procedure entails using any type of ignition source (such as an electrocautery or laser). (4) The prepped surgical area must be completely dry before applying any sterile surgical drapes or beginning the surgical procedure (for the same reasons as noted above). The prepped skin area should dry in approximately one to three minutes, once the prep is completed. However, if the solution gets into the patient's hair, blot the hair with a towel and allow additional time for the area to completely dry. ..."

Review on February 27, 2017, of the facility's granted Exception to 28 Pa. Code 123.25(2), relating to regulations for control of anesthetic explosion hazards, dated September 16, 2011, revealed "The facility shall use only solutions that: are prepackaged to ensure controlled delivery to the patient in unit-dose applicators, swabs or other similar applicators; and provide clear and explicit manufacturer / supplier instructions and warnings. The instructions for use shall be carefully followed. The facility shall ensure the skin preparation solutions, that contain combustible agents, do not soak into the patient's hair or linens. The facility shall ensure the skin preparation solution is completely dry prior to draping and shall inspect the prepped area to conform it is dry prior to draping. The facility will document in the patient's medical record that the above has occurred prior to the surgical procedure. ..."

Interview with EMP6, EMP7 and EMP8 on February 27, 2017, at approximately 10:45 AM revealed the facility routinely uses a flammable Chlorhexidine Gluconate surgical skin prep in interventional radiology (IR).

Review of MR1, MR2, MR31, MR32 and MR33 on February 27, 2017, revealed the patients had surgical procedures in interventional radiology. There was no documentation in MR1, MR2, MR31, MR32 and MR33 indicating staff allowed the Chlorhexidine Gluconate to dry prior to draping MR1, MR2, MR31, MR32 and MR33.

Interview with EMP6 and EMP7 on February 27, 2017, at approximately 11:00 AM confirmed MR1, MR2, MR31, MR32 and MR33 had surgical procedures in interventional radiology, and there was no documentation in the patients' medical records indicating staff allowed the Chlorhexidine Gluconate to dry prior to draping MR1, MR2, MR31, MR32 and MR33. EMP6 and EMP7 revealed there was no designated area for staff to document the Chlorhexidine Gluconate was allowed to dry prior to draping in the interventional radiology procedure documents. EMP7 revealed Chlorhexidine Gluconate was used as a skin prep on MR1, MR2, MR31, MR32 and MR33.