Nursing Investigation Results -

Pennsylvania Department of Health
LVH COORDINATED ALLENTOWN
Patient Care Inspection Results

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LVH COORDINATED ALLENTOWN
Inspection Results For:

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LVH COORDINATED ALLENTOWN - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

This report is the result of an unannounced onsite Medicare Recertification Survey conducted on October 28, 29, 30, and 31, 2019, at The Surgical Specialty Hospital at Coordinated Health. 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.

The following offsite locations were included in this survey:

CH-East Stroudsburg Campus
505 Independence Rd
East Stroudsburg, PA 18301

CH-East Stroudsburg Care on Demand
511 VNA Rd.
East Stroudsburg, PA 18301

CH-East Stroudsburg Ambulatory Surgery Center
511 VNA Rd.
East Stroudsburg, PA 18301








 Plan of Correction:


482.23(c)(4) STANDARD BLOOD TRANSFUSIONS AND IV MEDICATIONS:Not Assigned
Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. If blood transfusions and intravenous medications are administered by personnel other than doctors of medicine or osteopathy, the personnel must have special training for this duty.

Observations:


Based on review of facility documents, staff interview (EMP), and review of medical records it was determined the facility failed to follow the blood infusion protocol as per policy by failing to assess the patient at required time intervals for three of three medical records reviewed (MR15, MR16 and MR17).

Review on October 30, 2019, of the facility's policy, "Blood Transfusions," no date, revealed, "... 6. Infusion protocols: ... i. Assess the patient 5 minutes after start of transfusion, then 15, 30 and 60 minutes and every 60 minutes thereafter until transfusion complete ... ."

Review on October 30, 2019, of MR15 revealed this patient received a blood transfusion on September 6, 2019 with start time at 0945 and end time at 1300. Further revealed Assessments were documented at 1235 and 1335. Further revealed no documentation that an assessment was completed at 950, 1000, 1015, 1045, 1145 and 1245 as required by policy.

Review on October 30, 2019, of MR16 revealed this patient received a blood transfusion on August 30, 2019 with start time at 1048 and end time at 1320. Further revealed Assessments were documented at 1103, 1116 and 1320. Further revealed no documentation that an assessment was completed at 1053, 1148 and 1248 as required by policy.

Review on October 30, 2019, of MR17 revealed this patient received a blood transfusion on August 25, 2019 with start time at 1800 and end time at 2100. Further revealed Assessments were documented at 1750, 2000, 2020 and 2100. Further revealed no documentation that an assessment was completed at 1805, 1815, 1830, 1900 and 2000 as required by policy.

Interview on October 30, 2019, at approximately 11:00 AM, with EMP1 confirmed facility failed to follow the blood infusion protocol, as per policy by failing to assess the patients at required time intervals for three of three medical records reviewed (MR15, MR16 and MR17).







 Plan of Correction - To be completed: 12/30/2019

The Blood Transfusion policy was revised on 10/31/2019 to eliminate the requirement for an assessment at a specific timeframe and to require vital signs prior to initiation, 15 minutes after the start and at the completion. The staff was educated in the revised policy by the DON on or before 11/15/2019. This will be included in our blood bank audit that is completed monthly and reported to the Patient Safety Committee monthly. The Director of Nursing will be responsbile for assuring that the new policy is followed by the nursing staff.

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