Pennsylvania Department of Health
LANCASTER GENERAL HOSPITAL, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LANCASTER GENERAL HOSPITAL, THE
Inspection Results For:

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LANCASTER GENERAL HOSPITAL, THE - 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 CHL26C840H initiated on August 14, 2026, and completed on August 17, 2026, at Lancaster 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:

103.3 (8) LICENSURE GOVERNING BODY BYLAWS:

(8) Establish a procedure for processing and evaluating the applications for medical staff membership and for granting of clinical privileges.

Observations:
Based on review of facility policy, credential files (CF) and staff interview (EMP), it was determined the facility failed to ensure the policy for medical staff background checks were followed for six of ten credential files reviewed (CF1, CF2, CF3, CF6, CF7, and CF10).

Findings include:

Review on August 17, 2026, of the facility policy "Background Investigations" revealed "... G. Child Protective Services Laws - Employees in a position or department/practice that has direct contact with children (under 18 years of age) in the form of care, supervision, guidance or control of children or routine interaction with children must obtain the following background checks as a condition of employment: 1. Pennsylvania State Police Criminal History clearance (PATCH Report) 2. Pennsylvania Child Abuse Clearance (DPW Childline Clearance) 3. Federal (FBI) Criminal Background Check (using electronic fingerprinting through Cogent systems to DPW.) ... All new hires/transfers in positions requiring this screening are cleared as part of the onboarding process. Clearances must be repeated every five (5) years ..."

Review of credential files on August 17, 2026, revealed CF1 did not contain current Pennsylvania State Police Criminal History Clearance, Pennsylvania Child Abuse Clearance, or Federal Bureau of Investigation Criminal Background Check.

Review of credential files on August 17, 2026, revealed CF2 did not contain current Pennsylvania State Police Criminal History Clearance or Federal Bureau of Investigation Criminal Background Check.

Review of credential files on August 17, 2026, revealed CF3 did not contain current Pennsylvania State Police Criminal History Clearance or Federal Bureau of Investigation Criminal Background Check.

Review of credential files on August 17, 2026, revealed CF6 did not contain current Pennsylvania Child Abuse Clearance or Federal Bureau of Investigation Criminal Background Check.

Review of credential files on August 17, 2026, revealed CF7 did not contain current Pennsylvania State Police Criminal History Clearance, Pennsylvania Child Abuse Clearance, or Federal Bureau of Investigation Criminal Background Check.

Review of credential files on August 17, 2026, revealed CF10 did not contain current Pennsylvania State Police Criminal History Clearance.

Interview on August 17, 2026, with EMP13 confirmed the above findings.

Plan of Correction - To be completed: 10/23/2026

To prevent recurrence and maintain proper patient and staff safety, the following corrective actions have been reviewed and approved by the Chief Executive Officer (CEO). The CEO will provide ongoing oversight and monitoring of the implementation of these or similar actions, with regular reports submitted to the Board of Trustees directly or through its Executive Committee.

Action Step: Executive responsible for oversight of this portion of the Plan of Correction.
Responsible Party: Chief Human Resource Officer (CHRO)
Completion Date: August 24, 2026

Action Step: Complete a review of all non-employed providers to verify that they all have all required clearances.
Responsible Parties: CHRO and Manager Medical Staff Office
Completion Date: October 23, 2026

Action Step: Verify that the 6 physicians referred to in the citation obtain required Pennsylvania State Police Criminal History (PATCH), Pennsylvania Child Abuse (PCA) and Federal Bureau of Investigation Criminal Background Check (FBI) clearances.
Responsible Party: Associate Chief Medical Officer
Completion Date: October 23, 2026

Action Step: Review compliance to PATCH for non-employed and employed providers and bring them into compliance.
Responsible Parties: CHRO and Manager Medical Staff Office
Completion Date: October 23, 2026

Action Step: Develop process to flag upcoming expiring PATCH, PCA, and FBI clearances and follow up with provider to complete necessary actions to update clearance.
Responsible Parties: CHRO
Completion Date: October 23, 2026

Action Step: 20 provider files (10 employed and 10 non-employed) will be audited per month to verify required clearances are up-to-date with the goal of 100% compliance. Providers who are found to need clearances will not provide care until clearances are obtained.
Responsible Parties: CHRO and Manager Medical Staff Office
Completion Date: October 23, 2026

103.22 (b)(7) LICENSURE IMPLEMENTATION:

(7) The patient has the right to good quality care and high professional standards that are continually maintained and reviewed.

Observations:
Based on review of facility documents, medical record (MR), facility tour, and interview with staff (EMP), it was determined that the facility failed to maintain good quality care when they failed to adequately supervise and intervene to prevent the death of one in twenty medical records reviewed (MR1).

Findings include:

On August 14, 2026, review of facility policy "Patient Bill of Rights" last revised January 30, 2026, revealed "Policy Purpose: The purpose of this Policy is to set forth a procedure to inform all Lancaster General Health (LG Health) patients of their rights and responsibilities. ... Appendices: Patient's Bill of Rights and Responsibilities Attachment: Patient's Bill of Rights Lancaster General Hospital (LGH), as a healthcare facility within Lancaster General Health, is committed to delivering quality healthcare to you, our patient, and making your stay as pleasant as possible. The following Statement of The Patient's Rights and Responsibilities is endorsed by the Administration and staff of this facility and applies to all patients. ... 21. Right to a safe environment - Each patient has the right to receive care in a safe setting and to be free from all forms of abuse or harassment."

Review of facility document "Patient Safety Assistant (PSA) - Roles and responsibilities" revealed "The Patient Safety Assistant (PSA) ensures patient safety through continuous, direct observation, environmental safety, and prompt communication with the RN and care team. This role supports patients at risk for cognitive impairment, elopement, or high-risk suicide. Core Responsibilities - Continuous Observation & Safety - Maintain direct line-of-sight observation at all times. Respond immediately to safety concerns or behavior changes.
Keep the environment free of hazards, clutter, and ligature risks. Use de-escalation techniques to manage agitation or aggression."

Review of MR1 on August 14, 2026, revealed the patient was transported to the hospital on August 10, 2026, via ambulance for evaluation of altered mental status. The Patient had required pharmaceutical restraint during transport due to combative behavior. Once evaluated in the Emergency Department the patient was admitted to Intermediate Intensive Care Unit (ICU) for treatment. Patient presented with fever and abnormal kidney lab work. The drug and alcohol screening was negative. During hospitalization it was noted the patient exhibited agitated, aggressive, paranoid behaviors with hallucinations. A doctor ' s order for the patient to have a Cognitive Coach was put in place on August 11, 2026, at 1:41 AM, noting that the patient suddenly got up and ran towards the window. On August 11, 2026, at 2:29 AM it was noted that the patient was about to drink out of a urinal, agitated, hallucinating, and jumped out of bed wanting to go to window. During an exam on August 12, 2026, at 2:21 PM the patient would not actively engage in conversation with the physician and became agitated requiring to be medicated intermittently with Precedex. Nursing notes for August 13, 2026, continue to detail patient exhibiting paranoia as early as 2:00 AM to event noted at 9:30 AM. Leading to the incident, the patient was noted to be " pacing, defensive and cagey " with PtCA (Patient Care Assistant) sitting right outside of patient's room observing the patient. Both EMP9 and EMP10 noted seeing the patient hitting the window more than once with fists and head and ultimately breaking the window and exiting out of the window which resulted in the patient death.

Documentation for Cognitive Coach policy and job description was requested. None provided.

Interview with EMP11 on August 14, 2026, confirmed EMP12 (PtCa) was acting as PSA (Patient Safety Assistant) providing Cognitive Coach coverage at the time of incident. EMP11 also confirmed that EMP12, nor other staff, did not immediately enter the room or use de-escalation technique when the patient was pacing or hitting the window with fists and head.

Interview with EMP1 on August 14, 2026, EMP1 confirmed all information submitted and reviewed was complete and accurate.

Plan of Correction - To be completed: 10/23/2026

To prevent recurrence and maintain proper patient and staff safety, the following corrective actions have been reviewed and approved by the Chief Executive Officer (CEO). The CEO will provide ongoing oversight and monitoring of the implementation of these or similar actions, with regular reports submitted to the Board of Trustees directly or through its Executive Committee.

Action Step: Executive responsible for oversight of this portion of the Plan of Correction.
Responsible Party: Chief Nursing Officer
Completion Date: August 24, 2026

Action Step: Update Job Descriptions for Patient Safety Assistant (PSA) and Patient Care Assistant (PtCA) to reflect the roles and responsibilities associated with the Cognitive Coach function outlined in the plan of abatement dated August 17, 2026.
Responsible Party: Associate Chief Nursing Officer
Completion Date: September 5, 2026

Action Step: Revise Escalation of Care policy by defining when support staff should escalate to the Registered Nurse (RN) and the RN responsibilities and escalation process. Develop education for staff to the changes in the policy.
Responsible Party: Director of Nursing (DON)
Completion Date: September 15, 2026

Action Step: Educate Registered Nurse, PtCA and PSA staff to the policy revisions and escalation processes.
Responsible Party: DON
Completion Date: October 23, 2026

Action Step: Newly hired PSAs and PtCAs will complete Crisis Prevention Institute (CPI) foundational computer-based learning (CBL) prior to completing orientation and taking an independent assignment.
Responsible Party: DON
Completion Date: October 23, 2026

Action Step: Audit newly hired PSA and PtCA orientation classes to verify 100% compliance of completion of the CPI foundational CBL prior to their taking an independent assignment. Staff will be unable to accept assignment for their shift until CBL is completed.
Responsible Party: DON
Completion Date: October 23, 2026

107.61 LICENSURE MEDICAL ORDERS - WRITTEN ORDERS:

107.61 Written orders

Medication or treatment shall be
administered only upon written and
signed orders of a practitioner acting
within the scope of his license and
qualified according to medical staff
bylaws and 107.12(k) (relating to con-
tent of bylaws, rules and regulations)
except as provided in 107.62, 107.64, and
107.65. The date that the order was
written shall be included on all
written orders.

Observations:

Based on review of facility documents, medical records (MR), and staff interview (EMP) it was determined the facility failed to ensure all orders were written or authenticated by a practitioner for five of the 20 medical records reviewed (MR3, MR8, MR9, MR10, MR11).

Review of facility document "Medical Staff Rules and Regulations" dated January 21, 2026, revealed "7.0 Orders 7.1 All orders for treatment Shall be completed in the Electronic Health Record (EHR) by the responsible Practitioner unless the EHR is unavailable in which case paper forms will be available on all units. Only Practitioners with clinical privileges in this Hospital and Residents May sign orders within the medical record. No written order Shall be implemented unless it is signed. ... 7.5 A Protocol, Standing Orders and Order Sets Shall be ordered by a Practitioner for a specific patient, and Shall be dated, timed and authenticated."

Review of facility policy "Restraint and Seclusion" last revised January 1, 2026, revealed "Policy Purpose: The purpose of this policy is to ensure patient safety and eliminate the inappropriate use of restraint and seclusion on all patients, regardless of the patient location within the hospital. Procedure: General Procedures for Any Restraint Use ... 4. The nurse who is overseeing the care of the patient can initiate the use of restraint after obtaining an order from the LP or physician who is responsible for the care of the patient. 5. In an emergency situation, when the need for restraint intervention may occur so quickly that an order cannot be obtained prior to the application, the order must be obtained from the LP either during the emergency application or immediately (within a few minutes) after the restraint has been applied. ... 12. If restraints are discontinued prior to the expiration of the original order, a new order must be obtained prior to reapplying the restraint. Additional Procedures for Use of Restraints on Non-Violent / Non-Self-Destructive Patients 5. A physician or an LP may renew the original order or issue a new order if the restraint is clinically justified and continued use of the restraint beyond the first 24 hours is appropriate. The renewed order must be written on each calendar day and is based on examination of the patient by the LP or a physician.

Review of MR3 on August 17, 2026, revealed that on March 15, 2026, at 1:08 am orders for Restraints Violent, Coach, Alternative/Prevention of Delirium, Psychological Assessments Q 15 minutes, Vital Signs and Assess were entered and signed by EMP19. Then the orders were discontinued by EMP20 (RN) on March 15, 2026, at 3:51 am, the discontinuing of the orders were not written or authenticated by a provider.

Review of MR8 on August 17, 2026, revealed that on July 2, 2026, at 3:08 am orders for Restraints Violent, Cognitive Coach, Alternative/Prevention of Delirium, Psychological Assessments Q 15 minutes, Vital Signs and Assess were entered and signed by EMP23. Then the orders were discontinued by EMP15 (RN) on July 2, 2026, at 5:50 am, the discontinuing of the orders were not written or authenticated by a provider.
Additional review of MR8 on August 17, 2026, revealed that a Protocol order for One-to-One Observation with Qualified Staff was entered and signed by EMP24 (RN) on July 2, 2026, at 3:14 am, this order was not written or authenticated by a provider.

Review of MR9 on August 17, 2026, an order to Assess Temperature Every 1 hour was entered and signed by EMP16 (PA-C) on April 24, 2026, at 4:27pm. Then discontinued by EMP17 (RN) on May 1, 2026, at 3:57 am, the discontinuing of the order was not written or authenticated by a provider.
Additional review of MR9 on August 17, 2026, revealed an order for Restraints Non-Violent was entered and signed by EMP18 (RN) on April 27, 2026, at 8:33 am, this order was not written or authenticated by a provider.

Review of MR10 on August 17, 2026, revealed that on July 31, 2026, at 10:07 am orders for Restraints Non-Violent, Cognitive Coach, Alternative/Prevention of Delirium, Vital Signs and Assess Restraint were entered and signed by EMP9. Then the orders were discontinued by EMP21 (RN) on March 15, 2026, at 3:51 am, the discontinuing of the orders were not written or authenticated by a provider.
Additional review of MR10 on August 17, 2026, revealed an order for Restraints Non-Violent was entered and signed by EMP21 (RN) on July 31, 2026, at 2:44pm am, this order was not written or authenticated by a provider. Then the order was discontinued by EMP22 (RN) on July 31, 2026, at 9:01 pm, the discontinuing of the orders was not written or authenticated by a provider.

Review of MR11 on August 19, 2026, revealed orders Restraints Non-Violent, Assess Restraint Routine, Alternative/Prevention of Delerium, Vital Signs, Target Sedation Goal and Indwelling Urinary Catheter were authenticated by EMP14 on April 25, 2026, at 1:53 pm the orders were discontinued by EMP15 (RN) on April 26, 2026, at 6:53 am. The discontinuing of the orders was not written or authenticated by a provider.

Interview with EMP25 on August 17, 2026, EMP25 confirmed the above medical records did not follow facility policy and bylaws.

Plan of Correction - To be completed: 10/23/2026

To prevent recurrence and maintain proper patient and staff safety, the following corrective actions have been reviewed and approved by the Chief Executive Officer (CEO). The CEO will provide ongoing oversight and monitoring of the implementation of these or similar actions, with regular reports submitted to the Board of Trustees directly or through its Executive Committee.

Action Step: Executive responsible for oversight of this portion of the Plan of Correction.
Responsible Party: Chief Nursing Officer
Completion Date: August 24, 2026

Action Step: Revise Restraint and Seclusion Policy to outline who must place and discontinue orders and detail that patients must be removed from restraints at the earliest possible time that meets discontinuation criteria.
Responsible Party: Director of Nursing (DON)
Completion Date: September 5, 2026

Action Step: Educate RN staff to the revisions to the Restraint and Seclusion policy.
Responsible Party: DON
Completion Date: October 23, 2026

Action Step: 10 restraint order entry and 10 restraint order discontinuation entries will be audited per month to ensure appropriate order mode was used. Staff found to be noncompliant with expected order entry mode will be re-educated by nursing leadership. Audits will continue until 100% compliance is achieved for 3 consecutive months.
Responsible Party: DON
Completion Date: October 23, 2026

Action Steps: Change electronic medical record documentation option and workflow for the order mode of "Chart Cleanup" to require a provider co-signature.
Responsible Party: DON
Completion Date: September 30, 2026

Action Step: Revise Chart Check Policy and create education for the RNs around the changes to the policy regarding the need to select Chart Cleanup/Co-sign required when completing chart clean up.
Responsible Party: DON
Completion Date: September 10, 2026

Action Step: Educate RN staff to the revisions to the Chart Check policy and expectation of a provider cosignature being required when discontinuing or placing orders.
Responsible Party: DON
Completion Date: October 23, 2026

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