HospitalInspections.org

Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined that the facility failed to conform to all applicable State and Federal laws and regulations.

Select Speciality Hospital-York was not in compliance with the Adult Protective Services Act of October 7, 2010, P. L. 484, No. 70

This is not met as evidenced by:

Section 501. Reporting by employees.
(a) Mandatory reporting to agency.--
(1) An employee or an administrator who has reasonable cause to suspect that a recipient is a victim of abuse or neglect shall immediately make an oral report to an agency. If applicable, the agency shall advise the employee or administrator of additional reporting requirements that may pertain under subsection (b). An employee shall notify the administrator immediately following the report to the agency.
(2) Within 48 hours of making the oral report, the employee or administrator shall make a written report to the agency. The agency shall notify the administrator that a report of abuse has been made with the agency.

Findings include:

Based on a review of medical records (MR) and interview with staff (EMP) it was determined the facility failed to submit an oral report and written report for suspected verbal abuse for one of 11 medical records reviewed (MR11).

Findings include:

A review of MR11 on October 26, 2016, revealed "...Patient is awake, alert, oriented, answering questions and cognitively intact. {name redacted} had left-sided hemiplegia, complete."

An interview conducted on October 18, 2016, with EMP7, at 10:15 AM revealed EMP7 heard EMP5 saying things like "stop it, stop it, don't move, you know what happens when I get mad" and "get your leg down, you're not suppose to do that, you are getting me mad." EMP7 stated that he/she did report one verbal abuse allegation to administration, but did not report the second verbal abuse allegation to administration because "another employee reported it to administration." Further interview with EMP7 revealed EMP7 did not report any verbal abuse allegation as required by the Adult Protective Services Act 70. Further interview with EMP7 revealed he/she did not have any training/inservice on Act 70.

An interview conducted on October 18, 2016, with EMP2 revealed facility administration were notified of a verbal abuse allegation regarding a patient (MR11) on September 14, 2016, and September 24, 2016. The facility and/or employees did not report the verbal abuse allegations as required by the Adult Protective Services Act 70.

An interview conducted on October 18, 2016, with EMP6, at 10:10 AM revealed EMP6 was not aware of the Adult Protective Services Act 70.

An interview conducted on October 18, 2016, with EMP8, at 11:00 AM revealed EMP8 was not aware of the Adult Protective Services Act 70.

An interview conducted on October 18, 2016, with EMP10, at 11:10 AM revealed EMP10 was aware of the Adult Protective Services Act 70, but did not have any training/inservice on the Act.

An interview conducted on October 18, 2016, at 11:30 AM with EMP1 confirmed there was no policy that required the facility/employee to make a report, per Act 70, for suspected verbal abuse of an adult 18 years old to 60 years old. Further interview with EMP1 confirmed that no training had been provided to facility staff, with regard to the Adult Protective Services Act 70 of 2010.

Based on a review of facility policy and staff interview (EMP), it was determined the facility failed to ensure compliance with facility policy to properly report an allegation of verbal abuse.

Findings include:

A review of facility policy "Abuse, Neglect" last revised July 2012, revealed, "...Any Hospital employee suspecting a patient or visitor has been abused, neglected and/or harassed will immediately report the situation to the Chief Executive Officer, Chief Nursing Officer or administrator on-call immediately. The DQM and CNO will investigate according to the processes outlined in the Complaint and Grievance policy. Investigative findings will be kept in confidential file in the DQM's office. CNO or administrator will follow all State and Federal reporting requirements including notification of the local police, as appropriate. An allegation of abuse of a patient by staff, visitors, or other patients will result in removal of the patient (and others, as indicated) from any potential for harm or injury. Additionally, the Corporate Legal Department and the Corporation Human Resources Director, if the allegation involves an employee, should be notified. There will be no delay in removing patients from potential of danger pending notifications and investigation."

An interview conducted on October 18, 2016, at 9:30 AM with EMP1 confirmed that an employee reported, to administration, an allegation of verbal abuse by a staff member to a patient on September 14, 2016. EMP1 confirmed the facility investigated the allegation, but did not notify Corporate Legal Department and Corporate Human Resources Director as required per facility policy. Further interview with EMP1 revealed, "We should have contacted Corporate HR."

Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined that the facility failed to follow their established policy to ensure that there was a physician's order for the use of restraints for one of three restraint records reviewed (MR7).

Findings include:

A review on October 18, 2016, of facility policy entitled "Restraints and Seclusion" last revised, June 2012 revealed, " ... Any physician of the active medical staff, or licensed practitioner (if allowed under State law) may issue an order for restraint. Orders for restraints must be renewed on a daily basis. The order for a restraint may never be written as a standing order or on an as needed basis (PRN), and the order must be followed by consultation with the patient's treating physician as soon as possible. ..."

A review on October 18, 2016, of MR7's nursing documentation revealed the patient was in and out of restraints on June 12, 2016, and June 13, 2016. On June 12, 2016, the patient was in restraints from 7:00 AM to 9:00 AM and again from 7:00 PM to 11:00. On June 13, 2016, The patient was in restraints from 7:00 AM to 5:00 PM. MR7 failed to reveal physician's orders when the patient was put back in restraints. The Facillity was using restraints as prn (as needed).

An interview conducted on October 18, 2016, at 2:00 PM with EMP1 confirmed the facility was using the restraints as a prn order and the physician did not write an order each time the patient was put back in restraints.

Based on a review of facility documentation, medical records (MR) and staff interview(EMP), it was determined that the facility failed to ensure verbal orders were countersigned by a practitioner within seven days for two of ten medical records reviewed (MR7 and MR10).

Findings include:

Review of a letter from the Pennsylvania Department Of Health dated March 21, 2003, revealed "You requested to be permitted to extend the timeline for the authentication of verbal orders from 24 hours to seven (7) days. Based on the information submitted, your request was granted."

Review of facility policy, "Orders, Physician" dated 1/1/14, revealed, "Authentication: The responsible practitioner or another licensed independent practitioner within the same group practice or specialty of the responsible practitioner who is responsible for the patient's care shall authenticate, time and date all orders promptly, with the time frame specified by the state law ..."

A review of MR 7 revealed a verbal order dated September 5, 2016, that was authenticated by the physician on September 13, 2016; a verbal order dated September 4, 2016, that was authenticated by the physician on September 13, 2016, and a verbal order dated September 3, 2016, that was authenticated by the physician on September 13, 2016. Orders were not authenticated within seven days.

A review of MR10 revealed a verbal order dated July 26, 2016, that was not dated; a verbal order dated July 25, 2016, that was not dated and timed; a verbal order dated July 15, 2016, that was authenticated by the physician on July 26, 2016.

An interview conducted on October 18, 2016, at 11:00 AM with EMP1 confirmed the policy for authenticating verbal orders for MR7 and MR10 was not followed. EMP1 stated that verbal orders were not authenticated within seven days and orders were not timed and/or dated.