Pennsylvania Department of Health
INDIANA REGIONAL MEDICAL CENTER
Patient Care Inspection Results

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INDIANA REGIONAL MEDICAL CENTER
Inspection Results For:

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INDIANA REGIONAL MEDICAL CENTER - 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 (CHL23C643J) completed on March 5, 20234, at Indiana Regional Medical Center. 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:


103.22 (b)(1) LICENSURE IMPLEMENTATION:State only Deficiency.
(b) The following are minimal provisions for the Patient's Bill of Rights:

(1) The patient has the right to respectful care given by competent personnel.
Observations:

Based on review of medical records (MR) and facility documents and interview with staff (EMP), it was determined that the facility failed to administer respectful care by competent personnel by allowing High Fall Risk patients to be unsupervised by staff while on the commode in three of four patients (MR2, MR3 and MR4), and by allowing Licensed Practical Nurses to perform and document patient physical assessments independently without Registered Nurse attestation/verification in 14 of 18 medical records (MR7, MR8, MR9, MR10, MR11, MR13, MR14, MR15, MR16, MR18, MR19 MR20, MR22 and MR23).


Findings Include:

Indiana Regional Medical Center ... Policy#: P.C. 173 ... Subject: Patient Rights and Responsibilities ... Department of Origin: Nursing policy and procedure dated September 27, 2020. "... Policy: IRMC has a strong commitment to seeking, listening, and responding to our patients' needs and concerns. Care and/or treatment is provided by all members of the healthcare team based on each patients' age-specific needs. ... Patient Rights ... For your privacy, respect, dignity, and comfort, you have the right: You have the right to respectful care given by skilled staff. ... For our staff and environment, you have a right: To receive respectful care given by competent personnel in a setting that: ... For other health care services, you have a right: Effective and appropriate assessment and timely management of pain ... For quality, support and advocacy, you have a right: ... You have the right to respectful care and high professional standards that are provided by competent personnel. You have the right to expect good management techniques to be used, considering good use of your time and to avoid any personal discomfort. ... The health care providers of IRMC are committed to working with patients to deliver excellent patient care. ... ."


Indiana Regional Medical Center Subject: Fall Risk Assessment and Prevention Strategies Department of Origin: Quality policy and procedure dated June 12, 2023. "Purpose: To protect all patients, promote a culture of safety and make fall reduction a priority. To accurately assess, identify and institute evidence based interventions with patients who are at risk for falling/injury. To educate patients, families, supports and healthcare team members on measures to prevent falls and promote safety. Definition: A fall is defined as an unplanned, assisted or unassisted descent to the floor either with or without injuries to the patient/resident/client either witnessed or unwitnessed. Responsibility: Almost all hospitalized patients are at risk for falls/safety injuries and have the right to expect a safe environment. Many patients will not inform healthcare providers if they are at risk for falls. In fact, many patients do not look like they will fall. However, research has shown falls are the single most significant adverse event experienced in hospitals, negatively affecting physical and emotional health as well as overall quality of life. Fall Risk Assessment By Care Area A. Inpatient Areas: All patients 13 years and older admitted to the Intensive Care Unit (ICU), 7 Telemetry, 6 Medical, 4 Surgical, and Rehabilitation Care Center (RCC) will be assessed for risk of fall by using the Morse fall assessment. Low risk: 0-44 High risk: 45 or greater ... Procedure For Inpatient/BHS/RCC Fall Prevention 1. The admitting RN will assess the patient for the presence of fall risk factors and determine the patient's fall risk using the associated fall risk assessment. Fall risk assessments will be documented within the Adult Systems Assessment. 2. Patients with a Morse Fall Score of 45 or greater or a Wilson Sims score of 7 or greater will be determined high risk for falls. ... 3. If the patient has been determined to be high risk for fall, the nurse/designee shall ensure fall prevention measures are initiated. ... Patients at risk for falls will not be left unattended in the bathroom or at the bedside without an alarm engaged. ... General Fall Prevention Interventions All Patients 1. Educate patient regarding how to use the call bell for assistance, to request help when needing to get out of bed or use the restroom, the use of non-slip footwear. ... 3. Conduct hourly patient service (safety) rounds. Focus on the 4 P's: Positioning, Pain Score, personal assistance, and possessions within reach. ... High Risk for Fall [HRF] Patients Toileting 9. Staff will remain within an arm's length away of all HRF patients and until returned back to a monitoring process. ... ."



Indiana Regional Medical Center Subject: Assessment/Reassessment Department of Origin: Interdisciplinary/Organizational policy and procedure dated October 19, 2022. "Purpose: To ensure that all patients receive the appropriate assessment (including initial/screening and reassessment) provided by qualified individuals within the organization. Policy: All age groups of patients at Indiana Regional Medical Center receiving inpatient, outpatient, ER services will have an initial assessment and appropriate follow-up assessments, based upon their individual physical, psychological, and social/cultural needs and age specific needs. This assessment process will determine the need for care/treatment and the type of care to be provided throughout the continuum of care and prioritize. ... Assessment Framework The assessment framework will be structured around two components: initial screening and assessment and reassessment of all patients as appropriate to the clinical discipline and individual patient condition changes. I. General Information generated via a patient's assessment will be integrated with other disciplines to identify and prioritize the patient's needs for care and treatment. The various disciplines will share and provide information about their portion of the patient assessment relevant to their scope of care. ... Assessment of patients needing nursing care in all settings (departments) will be performed by an RN ... III. Reassessment A. Each clinical discipline will establish when the patient is to be reassessed. ... IV. Scope and Responsibilities of Involved Disciplines ... D. 1. At the time of admission, each patient will have his/her needs assessed by an RN. 2. The nursing admission history will be completed by the RN as soon as possible upon arrival to the nursing unit, but will not exceed the parameters for each unit. ... 3. a. When the history/assessment has been completed the Registered Nurse will identify the patient care needs or problems and develop a Care Plan based on identified needs. Any need/problem identified will be referred to the appropriate discipline for further assessment in accordance with their established criteria. b. In-patients will be assessed by an RN at least once every 24 hours to determine if nursing cared (sic) needs have been changed and will update the plan of care accordingly. Patient condition upon arrival may warrant immediate assessment. Unit-specific time frames are listed below: Area Med/Surg ... Completion Time required for admission assessment 4 Hours ... Area Telemetry ... Completion Time required for admission assessment 4 Hours ... Medical/Surgical/Telemetry/Pediatrics 1. The initial assessment is completed by the RN within the defined parameters. 2. Reassessment is performed at the beginning of an RN's shift and as indicated by the patient condition. ... ."

Review of 6th floor (MSC) RN job description February 2020, revealed, "... Job Specification ... Skills required (if applicable): Must possess nursing knowledge to effectively assess patients to formulate, implement and evaluate plans of care and document completely ... Must demonstrate commitment to service excellence and performance improvement. ... Job Summary Coordinates the provision of direct patient care according to Nursing Care Standards. The Registered/Graduate Nurse assesses, plans, implements, evaluates, and records patient care in accordance with the medical and nursing plans of care, policies and procedures. ... Directs and assists Licensed Practical Nurses, Nursing Assistants, and Nursing Students in rendering care to patients. Works collaboratively with all members of the patient care team and provides leadership so that standards of professional nursing practice are maintained in the clinical setting. ... Maintains responsibility and accountability for their individual professional practice and all actions as a licensed nurse for the quality of care delivered. ... ."

Review of "Initial Competency Assessment Checklist-Sixth Floor RN" revealed, "... Skill ... Documentation Admission Assessments ... Post Surgical Assessment Shift Assessment ... ."

Review of 6th floor (MSC) LPN job description dated November 2022, revealed, "... Job Specification ... Skills required (if applicable): A commitment to service excellence and performance improvement. ... Job Summary The LPN administers direct patient care to assigned patients under the direction and supervision of a GN/RN. ... ."

Review of "Initial Competency Assessment Checklist-Sixth Floor LPN" revealed, "... Skill ... Documentation ... Head to Toe assessment, must be verified by RN in the medical record ... ."




1. Review of "7th Cardiac & Neuro Care Unit Agenda & Discussion" meeting minutes dated September 2023, revealed, "... Staff Reminders ... FALLS-there have been an increase in falls on CNC. Please make sure bed alarms are engaged before leaving rooms. Do not leave a patient unattended in the bathroom or on the bedside commode. Reset the bed if the alarm will not turn on. ... ."

2. MR2 Morse Fall Risk Score documented as 60-85, yielded a High Fall Risk, revealed on February 5, 2024, at 4:43 AM patient had a fall from the commode, with post fall documentation that inlcuded patient was on anticoagulation therapy and fainted/seized. Additional nursing documentation revealed that the patient was found unresponsive on the floor after being placed on the bedside commode by the nurse aide.

MR3 Morse Fall Risk Score consistently documented as 60, yielded a High Fall Risk, revealed on June 29, 2023, at 10:50 AM patient had a fall from the commode with post fall documentation that included the fall was unassisted and unwitnessed and that the patient suffered a seizure and fell off the toilet.

MR4 Morse Fall Risk Score documented as 85-100, yielded a High Fall Risk, revealed on July 27, 2023, at 2:49 AM post fall documentation that included the fall from commode was unassisted and unwitnessed and that the patient went to get up from commode and feet slipped and patient sat on ground and sustained a scrape to left knee. Additional nursing documentation revealed that the patient was found on the bathroom floor by the RN and nurse aide.

Telephone interview with EMP1 on March 5, 2024, at 10:00 AM confirmed the above findings.


3. Review of facility electronic mail documentation dated January 10, 2024, revealed, "... Subject: Fw: RN/LPN Shared Responsibilities ... Task Shift Assessment ... LPN Document head to toe data in Cerner. RN Narrative note that RN assessment agrees with LPN charting. ... ."

4. MR7 dated November 2, 2023, at 8:00 AM revealed patient's physical assessment completed and documented by an LPN. MR7 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR8 dated November 6, 2023, at 9:50 AM revealed patient's physical assessment completed and documented by an LPN. MR8 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR9 dated November 7, 2023, at 8:39 AM revealed patient's physical assessment completed and documented by an LPN. MR9 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR10 dated November 7, 2023, at 8:00 AM revealed patient's physical assessment completed and documented by an LPN. MR10 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR11 dated November 8, 2023, at 9:15 AM revealed patient's physical assessment completed and documented by an LPN. MR11 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR13 dated November 11, 2023, at 7:15 AM revealed patient's physical assessment completed and documented by an LPN. MR13 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR14 dated November 15, 2023, at 10:30 AM revealed patient's physical assessment completed and documented by an LPN. MR14 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR15 dated November 19, 2023, at 10:10 AM revealed patient's physical assessment completed and documented by an LPN. MR15 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR16 dated November 20, 2023, at 9:00 AM revealed patient's physical assessment completed and documented by an LPN. MR16 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR18 dated November 26, 2023, at 10:19 AM revealed patient's physical assessment completed and documented by an LPN. MR18 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR19 dated November 28, 2023, at 9:00 AM revealed patient's physical assessment completed and documented by an LPN. MR19 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR20 dated November 29, 2023, at 8:05 AM revealed patient's physical assessment completed and documented by an LPN. MR20 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR22 dated December 25, 2023, at 8:56 AM revealed patient's physical assessment completed and documented by an LPN. MR22 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR23 dated December 30, 2023, at 8:41 AM revealed patient's physical assessment completed and documented by an LPN. MR23 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

Interview with EMP1 on February 22, 2024, at 1:00 PM revealed that following facility review of the above requested medical records, it was stated that there was noted to be a signifcant gap in the lack of RN documentation verifying the LPN's assessments.

Telephone interview with EMP1 on March 5, 2024, at 10:00 AM confirmed the above findings.











 Plan of Correction - To be completed: 03/15/2024

Re-education of the Fall Risk Assessment and Prevention Policy (#165) implemented March 13, 2024 as a UKG web-lesson to all registered nurses, licensed practical nurses, nursing assistants and therapy staff. Education includes staff acknowledgement and attestation that high-risk for fall patients will not be left unsupervised. Target date for staff completion is April 5, 2024.

Audits will be performed by Unit Managers, or designees, on all nursing units through direct observation of staff assistance with toileting high-risk for fall patients, as well as patient feedback during leader rounds. A total of 5 random audits will be performed weekly on each unit, beginning March 18, 2024 and continuing until 100% compliance is achieved over 30 days. Concurrent coaching will occur.

Further non-compliance with education or policy requirements will be addressed by Unit Managers through application of the Just Culture Algorithm, with formal coaching and corrective action, up to and including termination for repeated performance issues.

Fall incidents will be reported via the Incident Reporting process. A Post-Huddle follow-up will occur with documentation on Post-Fall form, submitted to the Unit Manager and Patient Safety Officer.

Action items and audit results will be reported to the Quality Patient Safety Council meeting on April 25, 2024 and the following scheduled Board of Directors' meeting, then, as needed, if further action is required to reach goals.

Re-education as a UKG web-lesson implemented March 13, 2024 to all RNs and LPNs including RN oversight of LPN physical assessments, with documented attestation in Cerner, per policy. Target date for staff completion is April 5, 2024.

Audits will be performed by the 6th floor Unit Manager, or designee, to verify RN attestation of LPN assessment is performed per policy. Audits will begin March 18, 2024 and continue until 100% compliance is achieved over 30 days.

Non-compliance with education or nurse practice requirements will be addressed by Unit Managers through application of the Just Culture Algorithm, with formal coaching and corrective action, up to and including termination for repeated performance issues.

Action items and audit results will be reported to the Quality Patient Safety Council meeting on April 25, 2024 and the following scheduled Board of Directors' meeting then, as needed, if further action is required to reach goals.

Added Patient Rights to a safe environment re-education, according to CMS Conditions of Participation, to 100% staff including registered nurses, licensed practical nurses, nursing assistants and therapy staff, utilizing daily department huddles, and requiring signed attestation.

109.5 LICENSURE AUXILIARY NURSING STAFF:State only Deficiency.
109.5 Auxiliary Nursing staff

Licensed practical nurses and other
nursing personnel shall be qualified
by training, education, experience,
and demonstrated abilities to give
nursing care that does not require the
skill and judgement of a registered or
professional nurse. Auxiliary nursing
personnel shall be supervised by a
professional nurse.
Observations:

Based on review of medical records (MR) and facility documents and interview with staff (EMP), it was determined that the facility failed to ensure the Registered Nurse supervised the Licensed Practical Nurse's patient physical assessments in 14 of 18 medical records (MR7, MR8, MR9, MR10, MR11, MR13, MR14, MR15, MR16, MR18, MR19 MR20, MR22 and MR23).

Findings Include:

Indiana Regional Medical Center Subject: Assessment/Reassessment Department of Origin: Interdisciplinary/Organizational policy and procedure dated October 19, 2022. "Purpose: To ensure that all patients receive the appropriate assessment (including initial/screening and reassessment) provided by qualified individuals within the organization. Policy: All age groups of patients at Indiana Regional Medical Center receiving inpatient, outpatient, ER services will have an initial assessment and appropriate follow-up assessments, based upon their individual physical, psychological, and social/cultural needs and age specific needs. This assessment process will determine the need for care/treatment and the type of care to be provided throughout the continuum of care and prioritize. ... Assessment Framework The assessment framework will be structured around two components: initial screening and assessment and reassessment of all patients as appropriate to the clinical discipline and individual patient condition changes. I. General Information generated via a patient's assessment will be integrated with other disciplines to identify and prioritize the patient's needs for care and treatment. The various disciplines will share and provide information about their portion of the patient assessment relevant to their scope of care. ... Assessment of patients needing nursing care in all settings (departments) will be performed by an RN ... III. Reassessment A. Each clinical discipline will establish when the patient is to be reassessed. ... IV. Scope and Responsibilities of Involved Disciplines ... D. 1. At the time of admission, each patient will have his/her needs assessed by an RN. 2. The nursing admission history will be completed by the RN as soon as possible upon arrival to the nursing unit, but will not exceed the parameters for each unit. ... 3. a. When the history/assessment has been completed the Registered Nurse will identify the patient care needs or problems and develop a Care Plan based on identified needs. Any need/problem identified will be referred to the appropriate discipline for further assessment in accordance with their established criteria. b. In-patients will be assessed by an RN at least once every 24 hours to determine if nursing cared (sic) needs have been changed and will update the plan of care accordingly. Patient condition upon arrival may warrant immediate assessment. Unit-specific time frames are listed below: Area Med/Surg ... Completion Time required for admission assessment 4 Hours ... Area Telemetry ... Completion Time required for admission assessment 4 Hours ... Medical/Surgical/Telemetry/Pediatrics 1. The initial assessment is completed by the RN within the defined parameters. 2. Reassessment is performed at the beginning of an RN's shift and as indicated by the patient condition. ... ."

Review of 6th floor (MSC) RN job description February 2020, revealed, "... Job Specification ... Skills required (if applicable): Must possess nursing knowledge to effectively assess patients to formulate, implement and evaluate plans of care and document completely ... Must demonstrate commitment to service excellence and performance improvement. ... Job Summary Coordinates the provision of direct patient care according to Nursing Care Standards. The Registered/Graduate Nurse assesses, plans, implements, evaluates, and records patient care in accordance with the medical and nursing plans of care, policies and procedures. ... Directs and assists Licensed Practical Nurses, Nursing Assistants, and Nursing Students in rendering care to patients. Works collaboratively with all members of the patient care team and provides leadership so that standards of professional nursing practice are maintained in the clinical setting. ... Maintains responsibility and accountability for their individual professional practice and all actions as a licensed nurse for the quality of care delivered. ... ."

Review of "Initial Competency Assessment Checklist-Sixth Floor RN" revealed, "... Skill ... Documentation Admission Assessments ... Post Surgical Assessment Shift Assessment ... ."

Review of 6th floor (MSC) LPN job description dated November 2022, revealed, "... Job Specification ... Skills required (if applicable): A commitment to service excellence and performance improvement. ... Job Summary The LPN administers direct patient care to assigned patients under the direction and supervision of a GN/RN. ... ."

Review of "Initial Competency Assessment Checklist-Sixth Floor LPN" revealed, "... Skill ... Documentation ... Head to Toe assessment, must be verified by RN in the medical record ... ."



1. Review of facility electronic mail documentation dated January 10, 2024, revealed, "... Subject: Fw: RN/LPN Shared Responsibilities ... Task Shift Assessment ... LPN Document head to toe data in Cerner. RN Narrative note that RN assessment agrees with LPN charting. ... ."

2. MR7 dated November 2, 2023, at 8:00 AM revealed patient's physical assessment completed and documented by an LPN. MR7 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR8 dated November 6, 2023, at 9:50 AM revealed patient's physical assessment completed and documented by an LPN. MR8 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR9 dated November 7, 2023, at 8:39 AM revealed patient's physical assessment completed and documented by an LPN. MR9 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR10 dated November 7, 2023, at 8:00 AM revealed patient's physical assessment completed and documented by an LPN. MR10 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR11 dated November 8, 2023, at 9:15 AM revealed patient's physical assessment completed and documented by an LPN. MR11 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR13 dated November 11, 2023, at 7:15 AM revealed patient's physical assessment completed and documented by an LPN. MR13 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR14 dated November 15, 2023, at 10:30 AM revealed patient's physical assessment completed and documented by an LPN. MR14 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR15 dated November 19, 2023, at 10:10 AM revealed patient's physical assessment completed and documented by an LPN. MR15 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR16 dated November 20, 2023, at 9:00 AM revealed patient's physical assessment completed and documented by an LPN. MR16 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR18 dated November 26, 2023, at 10:19 AM revealed patient's physical assessment completed and documented by an LPN. MR18 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR19 dated November 28, 2023, at 9:00 AM revealed patient's physical assessment completed and documented by an LPN. MR19 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR20 dated November 29, 2023, at 8:05 AM revealed patient's physical assessment completed and documented by an LPN. MR20 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR22 dated December 25, 2023, at 8:56 AM revealed patient's physical assessment completed and documented by an LPN. MR22 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

MR23 dated December 30, 2023, at 8:41 AM revealed patient's physical assessment completed and documented by an LPN. MR23 failed to reveal documented evidence that an RN verified/attested to the LPN's assessment.

Interview with EMP1 on February 22, 2024, at 1:00 PM revealed that following facility review of the above requested medical records, it was stated that there was noted to be a signifcant gap in the lack of RN documentation verifying the LPN's assessments.

Interview with EMP1 on March 5, 2024, at 10:00 AM confirmed the above findings.








 Plan of Correction - To be completed: 03/15/2024

Re-education as a UKG web-lesson implemented March 13, 2024 to all RNs and LPNs including RN oversight of LPN physical assessments, with documented attestation in Cerner, per policy. Target date for staff completion is April 5, 2024.

Audits will be performed by the 6th floor Unit Manager, or designee, to verify RN attestation of LPN assessment is performed per policy. Audits will begin March 18, 2024 and continue until 100% compliance is achieved over 30 days.

Non-compliance with education or nurse practice requirements will be addressed by Unit Managers through application of the Just Culture Algorithm, with formal coaching and corrective action, up to and including termination for repeated performance issues.

Action items and audit results will be reported to the Quality Patient Safety Council meeting on April 25, 2024 and the following scheduled Board of Directors' meeting then, as needed, if further action is required to reach goals.

The 6th floor implemented a pilot of TEAM NURSING CARE, with an RN and LPN assigned to the same patient group and patients' physical assessments completed by the RN. This began on March 14, 2023 and will continue for a period of 4 weeks with re-evaluation.


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