Pennsylvania Department of Health
PENN HIGHLANDS CONNELLSVILLE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PENN HIGHLANDS CONNELLSVILLE
Inspection Results For:

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PENN HIGHLANDS CONNELLSVILLE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of an unannounced onsite complaint investigation CHL25C436P completed on May 14, 2025, at Penn Highlands Connellsville. 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:

109.21 LICENSURE POLICIES - PRINCIPLE:

109.21 Principle

Written nursing care and administrative policies and procedures shall be developed to provide the nursing staff with methods of meeting its responsibilities and achieving goals.

Observations:

Based on a review of facility polices, medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that Behavioral Health Observation Policy was followed by the staff for one of one medical records reviewed (MR1).

Findings include:

On May 14, 2025, at 12:55 PM, a review of facility policy, "Behavioral Health Observation of Patients in the Emergency Department" dated 05/15/2024, revieled, "Policy: Individuals entering the emergency room are assessed for their degree of risk for self harm or elopement during the behavioral health triage assessment process. Routine observation of patients will be conducted by staff to assure patient safety on the unit. Procedure: 2. All behavioral health patients are placed in every 15- minute observation. Observation is determined either by a physician or nursing order. Nursing may place the patient in observation if deemed necessary. 3. Staff summarize their observations of behavior or verbalizations of assigned patients and interventions and record these in the electronic medical record (EMR). Constant Visual Observation: 1. The patient is to remain visible to staff member and /or sitter. 2. The patient's behavior or actions are documented on the observation log every fifteen (15) minutes. 3. The watch is continued until the physician discontinues it. 4. The patient is never left unattended by staff members ... Responsibilities of the Emergency Room Sitter: 1. Must document every 15 minutes on patient's behavior and physical actions. 2. The sitter must always be within an arm's length of the patient at all times. 3. Crisis Prevention Intervention Training is required biannually. 4. Must be physically capable of implementing Crisis Prevention Intervention (CPI) or the equivalent techniques as needed."

"Behavioral Health Observation of Patients (Connellsville)" last revised 1/7/2023; "PURPOSE: To ensure the safety of patients by providing an adequate level of nursing observation at all times ...Individuals entering the program are assessed for their degree of risk during the admission assessment process Routine observation of patients will be conducted by staff to assure patient safety ...all patients are placed on 15 minute observations. Observation type is determined either by a physicians or nursing order. Nursing may place the patient on closer observation than that ordered by a physician if deemed necessary." ... "Staff summarize their observations of behavior or verbalizations of assigned patients and interventions and record these in the medical record." ... "Description of Observation Levels. Routine 15-minute checks: 1. The patient is placed under staff observation every fifteen (15) minutes. The patient is visibly observed by a staff member every fifteen (15) minutes. The patient's location at the time of the check is documented on the Observation Log. Constant Visual Observation: The patient is to remain visible to a staff member. The patient's location is documented on the observation log every fifteen (15) minutes."

Review of MR1 revealed that on May 8, 2025 at 1:34 PM, a physician consult note was entered which stated "I was consulted for medical evaluation of lacerations sustained to the left forearm. Patient was on the BHU [Behavioral Health Unit] and apparently self cut in the left forearm. She has four lacerations total, two that are deeper, two superficial. She was brought over to the ED [Emergency Department] from BHU for medical consult" ... "Shortly after the procedure was completed I attended to another mental health crisis in the ED with another patient. When I returned from addressing that mental health crisis, this patient was not in the ED any longer. Code Green was called. It is presumed the patient had eloped while ED staff was attending to the mental health crisis involving another patient."

During an interview on May 14, 2025, at approximately 1:45 PM, EMP1 confirmed the above.

Plan of Correction - To be completed: 05/29/2025

To ensure the Behavioral Health patient's safety a new policy was developed and titled "Accompanying Behavioral Health Patients to the Emergency Room". This new policy includes language that staff is required to remain with the patient for the entire duration of the ER visit, including transporting to and from the BHU. This Administrative policy was approved by the Regional President 5/13/2025.
Staff education on the new process began 5/8/2025 in the Emergency Department and completed with 100% of Behavioral Health Staff by 5/28/2025.
To ensure compliance and adherence with the policy and new process of Behavioral Health staff remaining with the patient, the Director of Behavioral Health or designee will audit 100% of all Behavioral Health patients that require an ER visit for 3 months. If 100% compliance is not achieved the monitoring will continue until 100% compliance is achieved for 3 consecutive months. This will be reported to the Safety Excellence committee monthly during the duration of the audit period.
The Chief Nursing Office has ultimate responsibility to ensure compliance with this POC.

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