QA Investigation Results

Pennsylvania Department of Health
ALLEGHENY GENERAL HOSPITAL
Health Inspection Results
ALLEGHENY GENERAL HOSPITAL
Health Inspection Results For:


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Initial Comments:
This report is the result of an unannounced onsite complaint investigation (PIT19C010P) completed on May 16, 2019, at Allegheny General Hospital. It was determined that the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.






Plan of Correction:




482.13(a)(1) STANDARD
PATIENT RIGHTS: NOTICE OF RIGHTS

Name - Component - 00
A hospital must inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible.


Observations:

Based on a review of facility policy, medical records (MR), and staff interview (EMP), it was determined the facility failed to provide notice of patient rights for five of five medical records reviewed (MR18, MR19, MR20, MR21 and MR22).

Findings include:

Review of facility policy and procedure, "Patient Rights and Responsibilities," last reviewed January 2019, revealed, "... Patient Rights' Overview ... Allegheny General Hospital wants patients, and their family members or guardians, to know their rights under federal and Pennsylvania state law as soon as possible during a hospital stay. ..."

Review of MR18, MR29, MR20, MR21, and MR22 revealed no documentation patients were informed of their rights and responsibilities.

Interview with EMP1 on May 16, 2019 at 10:46 AM confirmed the above findings.





Plan of Correction:

The Director of Regulatory Affairs will share this deficiency with the Nursing Leadership. Nursing leadership will provide education to front line staff about this finding and the need to document that each patient has been provided a copy of the patient admission guide which contains the patient bill of rights.

Beginning in July, 2019 we will conduct the following audits:
- 50 charts each month of admitted patients to assure they have received a copy of the patient admission guide.

The results of the record audit will be analyzed on a monthly basis by the Director of Regulatory Affairs and Nursing leadership beginning in August, 2019 and will continue for three consecutive months or longer until 100% compliance is achieved.

Results of the review will be reported monthly beginning in August, 2019 to the Regulatory Readiness Committee.



482.55(a)(3) STANDARD
EMERGENCY SERVICES POLICIES

Name - Component - 00
[If emergency services are provided at the hospital --]

(3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff.


Observations:

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined the facility failed to follow their policy and procedure to transfer patients for three of three medical records reviewed (MR12, MR13, and MR14), and failed to follow their policy and procedure for providing emergency medical care by not continually reassessing abnormal vital signs for two of eleven medical records reviewed. (MR3 and MR17)
.
Findings include:

Review of facility policy and procedure "Admission, Discharge, Reservation, and Transfer of Patients" last approved May 2019, revealed "18. Patients shall only be discharged/transferred following a physician order."

1. Review of MR12, MR13, and MR14 on May 15, 2019, revealed the patients were transferred on April 13, 2019. Further review revealed no documentation of a physician order to transfer the patient, as per above policy.

2. Interview with EMP1 on May 16, 2019, at 9:35 AM confirmed the above findings and revealed, "when they put in the disposition as transfer they [the physicians] feel it is the order."

Review of facility policy "Triage and Vital Sign Assessment and Documentation" last reviewed August of 2018 revealed, "..Repeat vital signs are done according to the following schedule regardless of previously indicated time interval ...B. Abnormal Parameters 1. Vital signs (except temperature) are repeated within 30-60 minutes if not within the normal range for age...3. Notify physicians of all patients with abnormal vital signs... ."

1. MR17 presented to the facility's Emergency Department (ED) on January 24, 2019, at 19:51 after being involved in a motor vehicle collision and chief complaint on presentation to the ED was neck pain.

2. Review of MR17 revealed that at 19:59 on January 24, 2019 MR17's vital signs were assessed by facility and blood pressure was documented as 207 Systolic over 106 Diastolic.

3. Further review of MR17 revealed the patient was discharged from the ED at 23:33 and no reassessment of vital signs was completed by staff prior to discharge.

4. At 23:33 On January 24, 2019 an ED Physician Note revealed "BP 207/106, no repeats. Pt does have hx of HTN [hypertension]. Not addressed. Notify pt to f/u with PCP. Call #1: Contacted patient via cell phone and [patient] endorsed understanding that ...blood pressure was elevated ... "

5. MR3 presented to the facility's ED on April 8, 2019, and chief complaint on presentation to the ED was substance abuse.

6. Review of MR3 revealed that at 15:09 on April 8, 2019 vital signs were assessed by facility staff and blood pressure was documented as 151 Systolic over 104 Diastolic and heart rate was documented as 140.

7. Further review of MR3 revealed the patient was discharged from the ED at 15:49 and no reassessment of vital signs was completed by staff prior to discharge.

8. Interview was conducted with EMP1 on May 16, 2019 at 12:05 PM. EMP1 confirmed above findings.

























Plan of Correction:

The Director of Regulatory Affairs will share this deficiency with the Emergency Department. Emergency Department leadership will provide education to Emergency Department staff about this finding and the need to have :
- Appropriate assessment/reassessment for all patients and
- a transfer order for all patients being sent to another facility
ED leadership provided education to staff and physicians in daily huddle, in staff meetings and via the resident newsletter in June.

Beginning in July, 2019 we will conduct the following audits:
- 50 charts each month of patients being discharged home to assure they have vital signs taken within 30 minutes of their discharge.
- All patients transferred from the ED to another facility

The results of the record audit will be analyzed on a monthly basis by the Director of Regulatory Affairs and ED leadership beginning in August, 2019 and will continue for three consecutive months or longer until 100% compliance is achieved.

Results of the review will be reported monthly beginning in August, 2019 to the Regulatory Readiness Committee.



Initial Comments:

This report is the result of an unannounced onsite complaint investigation (PIT19C010P) completed on May 16, 2019, at Allegheny General Hospital. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.


Plan of Correction:




103.23 (1)(2) LICENSURE
PROCEDURES FOR DISTRIBUTION

Name - Component - 00
103.23 Procedures for distribution
The hospital shall develop procedures to inform each patient of his rights. Copies of the hospital's Patient's Bill of Rights shall be made generally available through one of the following ways:
(1) Prominent displays in appropriate locations in addition to copies available upon request.
(2) Provision of a copy to each patient or responsible party upon admission or as soon after admission as is feasible.

Observations:

Based on a review of facility policy, medical records (MR), and staff interview (EMP), it was determined the facility failed to provide notice of patient rights for five of five medical records reviewed (MR18, MR19, MR20, MR21 and MR22).

Findings include:

Review of facility policy and procedure, "Patient Rights and Responsibilities," last reviewed January 2019, revealed, "... Patient Rights' Overview ... Allegheny General Hospital wants patients, and their family members or guardians, to know their rights under federal and Pennsylvania state law as soon as possible during a hospital stay. ..."


Review of MR18, MR29, MR20, MR21, and MR22 revealed no documentation patients were informed of their rights and responsibilities.

Interview with EMP1 on May 16, 2019 at 10:46 AM confirmed the above findings.






Plan of Correction:

The Director of Regulatory Affairs will share this deficiency with the Nursing Leadership. Nursing leadership will provide education to front line staff about this finding and the need to document that each patient has been provided a copy of the patient admission guide which contains the patient bill of rights.

Beginning in July, 2019 we will conduct the following audits:
- 50 charts each month of admitted patients to assure they have received a copy of the patient admission guide.

The results of the record audit will be analyzed on a monthly basis by the Director of Regulatory Affairs and Nursing leadership beginning in August, 2019 and will continue for three consecutive months or longer until 100% compliance is achieved.

Results of the review will be reported monthly beginning in August, 2019 to the Regulatory Readiness Committee.



117.41 (b)(4) LICENSURE
EMERGENCY PATIENT CARE

Name - Component - 00
117.41 Emergency patient care
(b) Policies and procedures for
emergency patient care should, at a
minimum, do the following:
(4) Provide for the discharge of
patients only upon written orders of a
physician. Telephone discharge orders
may be accepted in accordance with
107.62 (relating to oral orders).

Observations:

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined the facility failed to follow their policy and procedure to transfer patients for three of three medical records reviewed (MR12, MR13, and MR14), and failed to follow their policy and procedure for providing emergency medical care by not continually reassessing abnormal vital signs for two of eleven medical records reviewed. (MR3 and MR17)
.
Findings include:

Review of facility policy and procedure "Admission, Discharge, Reservation, and Transfer of Patients" last approved May 2019, revealed "18. Patients shall only be discharged/transferred following a physician order."

1. Review of MR12, MR13, and MR14 on May 15, 2019, revealed the patients were transferred on April 13, 2019. Further review revealed no documentation of a physician order to transfer the patient, as per above policy.

2. Interview with EMP1 on May 16, 2019, at 9:35 AM confirmed the above findings and revealed, "when they put in the disposition as transfer they [the physicians] feel it is the order."

Review of facility policy "Triage and Vital Sign Assessment and Documentation" last reviewed August of 2018 revealed, "..Repeat vital signs are done according to the following schedule regardless of previously indicated time interval ...B. Abnormal Parameters 1. Vital signs (except temperature) are repeated within 30-60 minutes if not within the normal range for age...3. Notify physicians of all patients with abnormal vital signs... ."

1. MR17 presented to the facility's Emergency Department (ED) on January 24, 2019, at 19:51 after being involved in a motor vehicle collision and chief complaint on presentation to the ED was neck pain.

2. Review of MR17 revealed that at 19:59 on January 24, 2019 MR17's vital signs were assessed by facility and blood pressure was documented as 207 Systolic over 106 Diastolic.

3. Further review of MR17 revealed the patient was discharged from the ED at 23:33 and no reassessment of vital signs was completed by staff prior to discharge.

4. At 23:33 On January 24, 2019 an ED Physician Note revealed "BP 207/106, no repeats. Pt does have hx of HTN [hypertension]. Not addressed. Notify pt to f/u with PCP. Call #1: Contacted patient via cell phone and [patient] endorsed understanding that ...blood pressure was elevated ... "

5. MR3 presented to the facility's ED on April 8, 2019, and chief complaint on presentation to the ED was substance abuse.

6. Review of MR3 revealed that at 15:09 on April 8, 2019 vital signs were assessed by facility staff and blood pressure was documented as 151 Systolic over 104 Diastolic and heart rate was documented as 140.

7. Further review of MR3 revealed the patient was discharged from the ED at 15:49 and no reassessment of vital signs was completed by staff prior to discharge.

8. Interview was conducted with EMP1 on May 16, 2019 at 12:05 PM. EMP1 confirmed above findings.



















Plan of Correction:

The Director of Regulatory Affairs will share this deficiency with the Emergency Department. Emergency Department leadership will provide education to Emergency Department staff about this finding and the need to have :
- Appropriate assessment/reassessment for all patients and
- a transfer order for all patients being sent to another facility
ED leadership provided education to staff and physicians in daily huddle, in staff meetings and via the resident newsletter in June.

Beginning in July, 2019 we will conduct the following audits:
- 50 charts each month of patients being discharged home to assure they have vital signs taken within 30 minutes of their discharge.
- All patients transferred from the ED to another facility

The results of the record audit will be analyzed on a monthly basis by the Director of Regulatory Affairs and ED leadership beginning in August, 2019 and will continue for three consecutive months or longer until 100% compliance is achieved.

Results of the review will be reported monthly beginning in August, 2019 to the Regulatory Readiness Committee.