Pennsylvania Department of Health
ENDLESS MOUNTAINS HEALTH SYSTEMS, INC.
Patient Care Inspection Results

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ENDLESS MOUNTAINS HEALTH SYSTEMS, INC.
Inspection Results For:

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ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

This report is the result of a revisit conducted on-site on April 3, 2024, at Endless Mountains Health Systems, Inc. as the result of a previous complaint survey that was conducted on December 7, 2023. It was determined 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:


101.111 LICENSURE CORRECTION OF DEFICIENCY:State only Deficiency.
101.111 Policy

Whenever any hospital notifies the Department that it has completed a plan of correction and corrected its deficiencies, the Department will conduct a survey to ascertain completion of the plan of correction. Upon finding full or substantial compliance, as defined in 101.92(b), the Department may issue a regular license.
Observations:

Based on an unannounced follow-up on-site survey conducted on April 3, 2024, review of the facility's Plan of Correction (PoC), medical records (MR) and staff interview (EMP), it was determined Endless Mountains Health Systems failed to ensure patients presenting to the Emergency Department (ED) were assessed and received the correct Emergency Severity Index (ESI) level for three of six applicable ED medical records reviewed (MR1, MR2 and MR5); the facility failed to follow the accepted Plan of Correction and reeducate staff regarding assessing and assigning the correct ESI level for three of three employees (EMP4, EMP5 and EMP6) and the facility failed to ensure ED staff monitored and recorded patient vital signs for four of six applicable ED medical records reviewed (MR1, MR2, MR4 and MR5).

Findings include:

Review of 117.12 Procedures
The PoC stated "1. ED 003-002 Triage of Emergency Patients and ED 003-003 Assessment and Reassessment polices will be reviewed and/or revised as necessary. 2. ED staff will be educated regarding ED 003-003 Triage of Emergency Patients and ED 003-003 Assessment and Reassessment policies with any changes/revisions reviewed with a focus on ESI levels and the importance of utilizing only EMHS approved assessments/scales. Education will be completed by January 19. 3. A protocol will be developed for nursing staff is to follow when a patient presents with signs and symptoms of a stroke. This protocol with be developed, education completed for an implementation date of January 19, 2024. 4. A random audit of 10 charts of all patients presenting to the ED will be reviewed each week for a period of 6 weeks to assure 100% compliance with policy and procedure, including assignment of appropriate ESI level. 5. 100% of charts of patients presenting with signs and symptoms of stroke will be reviewed each week for a period of 6 weeks to assure 100% compliance with policy and procedure. 6. Random chart audits will be done for both ESI level and signs and symptoms of stroke after that time. Chart review will be done by CNO, ED Nurse manager and/or designees. 7. Any deviation from the policy and procedure found during the monitoring will be reported to the CEO. Any individual deviating from the process will be reeducated. Reeducation to include review of the policy and procedure." All corrective actions would be completed by January 19, 2024.

Cross reference
117.41 (a) Emergency Patient Care

Review of 117.41 (a) Emergency Patient Care
The PoC stated "1. NU 004-013 Vital Sign Policy and NU-004-019 Neurological Assessments will be reviewed and/or revised as necessary. 2. ED staff will be educated on NU -004-013 Vital Sign Policy and NU-004-019 Neurological Assessments with any changes/revisions reviewed with a focus on the care of patients presenting with the signs and symptoms of a stroke. Education will also include education regarding the need for additional neurological assessments on any patient experiencing signs and symptoms of a stroke and the need to monitor any changes. This will be completed by January 19, 2024. 3. 100% of charts of patients presenting with signs and symptoms of a stroke will be reviewed each week for a period of 6 weeks to assure 100% compliance with the policy and procedure. This review will include compliance of additional neurological assessments being done as needed and the monitoring of any changes in neurological changes with appropriate care given. Random chart audits will be done after that time. Chart review will be done by CNO, ED Nurse manager and/or designees. 4. Any deviation from the policy and procedure found during the monitoring will be reported to the CEO. Any individual deviating from the process will be reeducated. Reeducation to include review of the policy and procedure. 5. Development of a protocol nursing staff is to follow when a patient presents with signs and symptoms of a stroke. This is to include a focus on the finding of the care of a patient with an elevated blood pressure when presenting with the signs and symptoms of a stroke. This protocol will be developed, education completed by 1/19/2024. 6. All charts reviewed under this plan of correction will include a review of vital signs monitoring and documentation in compliance with policy NU 004-013. 100% of charts of patients presenting with signs and symptoms of a stroke will be reviewed each week for a period of 6 weeks to assure 100% compliance with the policy and procedure." All corrective actions would be completed by January 19, 2024.

Cross reference
117.12 Procedures






 Plan of Correction - To be completed: 05/17/2024

1. ED 003-002 Triage of Emergency Patients and ED 003-003 Assessment and Reassessment polices will be reviewed and/or revised as necessary.
2. ED staff will be educated regarding ED 003-003 Triage of Emergency Patients policy with any changes/revisions reviewed with a focus on ESI levels and the importance of utilizing only EMHS approved assessments/scales.
3. ED staff will be educated regarding ED 003-003 Assessment and Reassessment In The Emergency Department with a focus on the assessment of signs per that policy.
4. A random audit of 10 charts of all patients presenting to the ED will be reviewed each week for a period of 6 weeks to assure 100% compliance with policy and procedure with a focus on the assignment of the correct ESI number and the completion of vital signs per policy. Chart review will be done by CNO, ED Nurse Manager and/or designees.
5. Any individual deviating from the process assigning an incorrect ESI number and/or monitoring of vital signs will be reeducated on the process. Reeducation to include review of the policy and procedure. The completion of the reeducation will be documented. A random audit of 3 charts per week for 6 weeks will be done on any individual requiring reeducation of the process. At the end of the 6 weeks a reevaluation will be done.
6. The above will be completed by May 17, 2024. The CEO/CNO and./or designees will monitor compliance.


109.52 (c) LICENSURE ORIENTAION AND CONTINUING EDUCATION:State only Deficiency.
109.52
(c) The education program may be conducted using resources internal or external to the hospital. Teaching material and suitable reference shall be supplied as needed for each nursing unit and special care unit.
Observations:

Based on an unannounced follow-up on-site survey conducted on April 4, 2024, review of the facility's Plan of Correction (PoC), medical records (MR) and staff interview (EMP), it was determined the facility failed to reeducate staff regarding assessing and assigning the correct ESI level for three of three employees (EMP4, EMP5 and EMP6) as indicated in the facility's Plan of Correction (PoC).

Findings include:

Review of the facility's PoC, approved December 19, 2023, revealed ED staff will be educated regarding ED 003-003 Triage of Emergency Patients and any individual deviating from the process will be reeducated. Reeducation to include review of the policy and procedure.

Review of MR1 on April 3, 2024, revealed this patient presented to the ED on January 27, 2024, with complaint of shortness of breath, weakness, trouble breathing and was clammy. EMP4 triaged MR1 and assigned this patient an ESI of 4 (non-urgent).

Interview with EMP2 and EMP3 on April 3, 2024, at the time of the medical record review revealed MR1 met the criteria of an ESI level of 3 (urgent) and not an ESI level of 4 (non-urgent). EMP3 revealed EMP4 did not properly assign the correct ESI level on MR1.

A request was made of EMP3 on April 3, 2024, for the documentation indicating EMP4's reeducation to the facility's ED 003-003 Triage of Emergency Patients policy. None was provided.

Review of MR2 on April 3, 2024, revealed this patient presented to the ED on January 22, 2024, with complaint of angina (a type of chest pain caused by reduced blood flow to the heart), shortness of breath, chest pain, chest tightness and shortness of breath. EMP5 triaged MR2 and assigned this patient an ESI of 3 (urgent).

Interview with EMP3 on April 3, 2024, at the time of the medical record review revealed MR2 met the criteria of an ESI level of 2 (Emergent). EMP3 revealed EMP5 did not properly assign the correct ESI level on MR2.

A request was made of EMP3 on April 3, 2024, for the documentation indicating EMP5's reeducation to the facility's ED 003-003 Triage of Emergency Patients policy. None was provided.

Review of MR5 on April 3, 2024, revealed this patient presented to the ED on February 11, 2024, with complaint of sudden onset of left side chest pain and shortness of breath. EMP6 triaged MR5 and assigned this patient an ESI of 3 (urgent).

Interview with EMP3 on April 3, 2024, at the time of the medical record review revealed MR5 met the criteria of an ESI level of 2 (Emergent). EMP3 revealed EMP6 did not properly assign the correct ESI level on MR2.

A request was made of EMP3 on April 3, 2024, for the documentation indicating EMP6's reeducation to the facility's ED 003-003 Triage of Emergency Patients policy. None was provided.

Interview with EMP3 on April 3, 2024, revealed there is no documentation indicating EMP4, EMP5 and EMP6 were reeducated on the facility's ED 003-003 Triage of Emergency Patients policy.

Cross reference
117.12 Procedures








 Plan of Correction - To be completed: 05/17/2024

1. An educational tool will be developed and ED nursing staff will be educated on assessing and assigning the correct ESI level for all patients presenting to the ED.
2. Any individual deviating from the process by assigning an incorrect ESI number will be reeducated on the process. Reeducation to include review of the policy and procedure. The completion of the reeducation will be documented. A random audit of 3 charts per week for 6 weeks will be done on any individual requiring reeducation of the process.
3. A random audit of 10 charts of all patients presenting to the ED will be reviewed for a period of 6 weeks to assure 100% compliance with policy and procedure regarding the assessment and assignment of the correct ESI level for all patients presenting to the ED.
4. The above will be completed by Friday May 17. CEO/CNO and/or designees will monitor for compliance.

117.12 LICENSURE PROCEDURES:State only Deficiency.
117.12 Procedures

Every hospital shall have established procedures whereby the ill or injured person can be assessed and either treated, referred to an appropriate facility, or discharged, as indicated.
Observations:

Based on an unannounced follow-up on-site survey conducted on April 4, 2024, review of the facility's Plan of Correction (PoC), medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure patients presenting to the Emergency Department (ED) were assessed and received the correct Emergency Severity Index (ESI) level for three of six applicable ED medical records reviewed (MR1, MR2 and MR5).
Findings include:
Review on April 3, 2024, of the facility's "Triage" policy, last approved October 20, 2020, revealed "...Policy: The triage area shall be an area or room, with a telephone with direct access to the Emergency Department. Direct bedding is the standard of care in this Emergency Department. Procedure: 1. The registered nurse will evaluate and categorize each patient upon arrival to the Emergency Department with an Emergency Severity Index (ESI) score and chief complaint. ... Defined Emergency Severity Index (ESI) ...Emergent (Level 2) - High risk situation / Disoriented, lethargic / confused / severe pain, distress Major injury or illness; requires immediate nursing intervention. Physician should evaluate within 30 minutes. Examples of Level 2 as follows: a. Chest pain, suspicious for acute coronary syndrome, stable b. Signs of a stroke / patient with worst headache of their life ...k. Any patient with unstable vital signs acutely ...Urgent (Level 3) - Patient will require the use of two or more resources. Treatment and reassessment should occur in 30 minutes. a. Abdominal pain b. Alcohol / drug intoxication c. Bleeding, patient is stable d. Closed fracture e. Drug ingestion f. Eye injury (no vision loss) g. Laceration h. Minor chest pain i. Non-cardiac chest pain j. Renal calculi k. Urinary retention Non-Urgent (Level 4) - Patient will require one resource. Treatment and reassessment should occur in one to two (1 - 2) hours: a. Abscess b. Constipation c. Cystitis d. Earache e. Minor lacerations f. Minor burn g. Sore throat h. Sprains/strains i. STD ' s j. Vaginal discharge Minor (Level 5) - Patient will not require any resources for treatment. Treatment and reassessment should occur within four (4) hours: a. Bruise b. Cough, non-productive c. Medication refill d. Routine physical e. Suture removal ..."

Review of MR1 on April 3, 2024, revealed this patient presented to the Emergency Department (ED) on January 27, 2024, with complaint of shortness of breath, weakness, trouble breathing and was clammy (a sign of a potential serious medical condition). EMP4 triaged MR1 and assigned this patient an ESI of 4 (non-urgent).

Interview with EMP2 and EMP3 on April 3, 2024, at the time of the medical record review revealed MR1 met the criteria of an ESI level of 3 (urgent) and not an ESI level of 4 (non-urgent).

Review of MR2 on April 3, 2024, revealed this patient presented to the ED on January 22, 2024, with complaint of angina (a type of chest pain caused by reduced blood flow to the heart), shortness of breath, chest pain, chest tightness and shortness of breath. EMP5 triaged MR2 and assigned this patient an ESI of 3 (urgent).

Interview with EMP3 on April 3, 2024, at the time of the medical record review revealed MR2 met the criteria of an ESI level of 2 (Emergent).

Review of MR5 on April 3, 2024, revealed this patient presented to the ED on February 11, 2024, with complaint of sudden onset of left side chest pain and shortness of breath. EMP6 triaged MR5 and assigned this patient an ESI of 3 (urgent).

Interview with EMP3 on April 3, 2024, at the time of the medical record review revealed MR5 met the criteria of an ESI level of 2 (Emergent). MR5 was transferred to another hospital for evaluation and treatment of a cardiac condition.

Continuing deficiency
December 7, 2023

Cross reference
101.111 Correction Of Deficiency

Cross reference
109.52 (c) Orientation And Continuing Education

Cross reference
117.41(a) Emergency Patient Care








 Plan of Correction - To be completed: 05/17/2024

1. ED staff will be educated regarding ED 003-003 Triage of Emergency Patients policy with any changes/revisions reviewed with a focus on ESI levels and the importance of utilizing only EMHS approved assessments/scales.
2. A random audit of 10 charts of all patients presenting to the ED will be reviewed each week for a period of 6 weeks to assure 100% compliance with policy and procedure with a focus on the assignment of the correct ESI number. Chart review will be done by CNO, ED Nurse Manager and/or designees.
3. Any individual deviating from the process assigning an incorrect ESI number will be reeducated on the process. Reeducation to include review of the policy and procedure. The completion of the reeducation will be documented. A random audit of 3 charts per week for 6 weeks will be done on any individual requiring reeducation of the process.
4. The above will be completed by Friday May 17, 2024. The CEO/CNO and/or designee will monitor for compliance.



117.41 (a) LICENSURE EMERGENCY PATIENT CARE:State only Deficiency.
117.41 Emergency patient care
(a) Emergency patient care shall be
guided by written policies and
procedures which delineate the proper
administrative and medical procedures
and methods to be followed in
providing emergency care. These
policies and procedures shall be clear
and explicit; approved by the medical
staff and hospital governing body;
reviewed annually, revised as
necessary; and dated to indicate the
date of the latest review or revision,
or both.
Observations:

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure vital signs were completed every 15 minutes on patients in the Emergency Department (ED) for four of six applicable ED medical records reviewed (MR1, MR2, MR4 and MR5).

Findings include:

Review of December 7, 2023, of the facility's "Assessment and Reassessment in the Emergency Department" policy, last approved June 20, 2018, revealed "Purpose - To provide all patients entering the Emergency Department with nursing care based on documented assessment of their needs by Emergency Nurses who possess current, comprehensive knowledge and skills in emergency healthcare. The nursing assessment, planning, interventions, evaluation of changes in the patient's condition, responses to interventions and outcomes of care shall be documented on the patient record. Policy - The Emergency Department (ED) nurses shall initiate accurate and ongoing assessment of physical and psychological needs of patients within the Emergency Department Reassessment of patients will be done on a regular basis to determine the patient's response to treatment; note significant changes in the patient's condition and / or patient's diagnosis ...2. All patients admitted to the Emergency Department will have the following documentation: ... b. Initial vital signs: i. Additional vital signs shall be obtained depending on patient's condition. ii. Critical patients every five (5) to 15 minutes as needed iii. Intermediate every one (1) hour iv. All other patients every two (2) hours or prior to discharge ..."

Review of MR1 on April 3, 2024, revealed this patient presented to the Emergency Department (ED) on January 27, 2024, at 0923 with complaint of shortness of breath, weakness, trouble breathing and was clammy. EMP4 triaged MR1 and assigned this patient an ESI of 4. The ED physician wrote orders instructing nursing staff to obtain vital signs every 2 hours and to monitor MR1's pulse oximetry every hour.

Review of MR1 on April 3, 2024, revealed nursing staff documented the following vital signs on MR1 on January 27, 2024:
At 0931 - Temperature 99.6, Pulse Rate 82, Respiratory Rate 20, Blood Pressure 149/77 and O2 Sat by Pulse Oximetry 90 L
At 1248 - O2 Sat by Pulse Oximetry 91 L
At 1325 - Temperature 97.7, Pulse Rate 67, Respiratory Rate 22, Blood Pressure 98/61 and O2 Sat by Pulse Oximetry 91 L.

MR1 was discharged to home at 1325.

There was no documentation in MR1 indicating nursing staff documented MR1's vital every 2 hours and pulse oximetry every hour as instructed by the ED physician.

Interview with EMP3 at the time of the medical record review confirmed the above findings.

Review of MR2 on April 3, 2024, revealed this patient presented to the ED on January 22, 2024, at 1134 with complaint of angina (a type of chest pain caused by reduced blood flow to the heart), shortness of breath, chest pain, chest tightness and shortness of breath. EMP5 triaged MR2 and assigned this patient an ESI of 3. The ED physician wrote orders instructing nursing staff to obtain vital signs every 2 hours.

Review of MR2 on April 3, 2024, revealed nursing staff documented the following vital signs on MR2 on January 22, 2924:
At 1148 - Temperature 98.5, Pulse Rate 83, Respiratory Rate 18, Blood Pressure 145/83 and O2 Sat by Pulse Oximetry 99 L
At 1454 - Temperature 98.5, Pulse Rate 83, Respiratory Rate 18, Blood Pressure 145/83 and O2 Sat by Pulse Oximetry 99 L

MR2 was discharged to home at 1454.

There was no documentation in MR2 indicating nursing staff documented MR2's vital every 2 hours as instructed by the ED physician.

Interview with EMP3 at the time of the medical record review confirmed the above findings.

Review of MR4 on April 3, 2024, revealed this patient presented to the ED on February 2, 2024, at 1427 with complaint of slurred speech, headache and feeling off balance. EMP7 triaged MR4 and assigned this patient an ESI of 2. The ED physician wrote orders instructing nursing staff to obtain MR4's blood pressure every 15 minutes.

Review of MR4 on April 3, 2024, revealed nursing staff documented the following blood pressure on MR4 on February 2, 2024:
At 1430 - 146/75
At 1445 - 144/71
At 1500 - 159/76
At 1515 - 148/65
At 1545 - 147/69
At 1605 - 121/55
At 1630 - 156/67
At 1700 - 116/79

MR4 was transferred to an outside hospital for further evaluation and treatment on February 5, 2024, at 1715.

There was no documentation in MR4 indicating nursing staff documented MR4's blood pressure every 15 minutes as instructed by the ED physician.

Interview with EMP3 at the time of the medical record review confirmed the above findings.

Review of MR5 on April 3, 2024, revealed this patient presented to the ED on February 11, 2024, at 0049 with complaint of chest pain and shortness of breath. EMP6 triaged MR5 and assigned this patient an ESI of 3. The ED physician wrote orders instructing nursing staff to obtain MR5's blood pressure every 15 minutes.

Review of MR5 on April 3, 2024, revealed nursing staff documented the following blood pressure on MR5 on February 11, 2024:
At 0104 - 116/76
At 0150 - 167/102
At 0154 - 124/85
At 0204 - 114/77
At 0641 - 115/72

MR5 was transferred to an outside hospital for further evaluation and treatment on February 11, 2024, at 0900.

There was no documentation in MR5 indicating nursing staff documented MR5's blood pressure every 15 minutes as instructed by the ED physician.

Interview with EMP3 at the time of the medical record review confirmed the above findings.

Continuing deficiency
December 7, 2023

Cross reference (0147)
101.111 Correction Of Deficiency

Cross reference (1706)
117.12 Procedures







 Plan of Correction - To be completed: 05/17/2024

1. ED 003-003 Assessment and Reassessment policy will be reviewed and/or revised as necessary.
2. ED staff will be educated regarding ED 003-003 Assessment and Reassessment the Emergency Department with a focus on the monitoring and the completion of vital signs per that policy.
3. A random audit of 10 charts of all patients presenting to the ED will be reviewed each week for a period of 6 weeks to assure 100% compliance with policy and procedure with a focus on the completion of vital signs per policy. Chart review will be done by CNO, ED Nurse Manager and/or designees.
4. Any individual deviating from the process of monitoring vital signs will be reeducated on the process. Reeducation to include review of the policy and procedure. The completion of the reeducation will be documented. A random audit of 3 charts per week for 6 weeks will be done on any individual requiring reeducation of the process. At the end of the 6 weeks a reevaluation will be done.
5. The above will be completed by May 17, 2024. The CEO/CNO and/ or designees will monitor for compliance.




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