Pennsylvania Department of Health
WEST PENN HOSPITAL
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WEST PENN HOSPITAL
Inspection Results For:

There are  272 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
WEST PENN HOSPITAL - 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 completed on April 3, 2024, at West Penn 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:


Initial comments:

This report is the result of an unannounced onsite complaint investigation (PA00069983) completed on April 3, 2024, at West Penn Hospital. It was determined the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.





 Plan of Correction:


482.23(b)(3) STANDARD RN SUPERVISION OF NURSING CARE:Not Assigned
A registered nurse must supervise and evaluate the nursing care for each patient.

Observations:


Based on a review of facility documentation, medical records (MR), and staff interviews (EMP) it was determined the facility failed to provide evidence in the medical record that a registered nurse (licensed professional nurse) supervised and evaluated nursing care of each patient for 4 of 20 medical records reviewed. (MR1, MR2, MR7, and MR9).


Findings include:


On April 3, 2024, review of facility policy, POL 6511361, "Licensed Practical Nurse (LPN) Role ", last approved September 26, 2023, revealed: " ... It is the policy that AHN utilizes and allows the Licensed Practical Nurse (LPN) to function as a member of the health care team ... The LPN may participate in planning, implementation, and evaluation of nursing care using focused assessment in settings where nursing takes place. ...". Further review of this policy revealed: "... Terms and Definitions: Focused assessment - Appraisal of an individual's current status and situation, which contributes to [the] comprehensive assessment by the licensed professional nurse and supports ongoing data collection. ...".


Review of MR1 revealed that the patient was cared for by a licensed practical nurse (EMP6) between February 25, 2024, at 7:00 PM, and February 26, 2024, at 7:00 AM. Further review of MR1 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during this shift.


Review of MR2 revealed that the patient was cared for by a licensed practical nurse (EMP11) between March 30, 2024, at 7:00 PM, and March 31, 2024, at 7:00 AM. Further review of MR2 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during this shift.


Review of MR7 revealed that the patient was cared for by a licensed practical nurse (EMP11) between March 28, 2024, at 7:00 AM, and March 28, 2024, at 7:00 PM. Further review of MR7 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during this shift.


Review of MR9 revealed that the patient was cared for by a licensed practical nurse (EMP11) on March 27, 2024 and March 28, 2024 from 7:00 AM to 7:00 PM. Further review of MR9 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during the shifts(s).


The above findings were confirmed for MR1, MR2, and MR7 during MR review with EMP4 on April 3, 2024, between 12:00 PM and 1:50 PM.


The above finding for MR9 was confirmed on April 3, 2024, during MR review with EMP5 on April 3, 2024, at 12:21 PM.













 Plan of Correction - To be completed: 06/01/2024

The Chief Nursing Officer (CNO) is ultimately responsible for this Plan of Correction. The CNO is accountable to the CEO for this plan of correction.
An interdisciplinary group collaborated on the plan of correction below, In order to protect patients in similar situations, and in order to ensure that this problem does not reoccur., an interdisciplinary group worked together to create the plan of correction below.

Licensed Practical Nurse (LPN) Role Policy will be revised to include the requirements of a Registered Nurse to supervise nursing care where an LPN is assigned a patient by May 21st.
RN's and LPN's will be educated to the new policy and procedure on Units where LPN's are assigned to a patient care assignment by June 1st.
Rehab Nurse Manager/designee will audit 5 rehab patient charts, weekly for 3 months, on the Rehab unit where an LPN is assigned patients to ensure RN supervision of nursing care during the shift by an RN has occurred. Audits will begin in June 2024 and continue until compliance with all components is 100% for three (3) consecutive months to ensure that the education was effective.
The Manager of Regulatory Readiness, or their designee, will report the results of the audits to the Performance Improvement Oversight Committee (PIOC) monthly and the WPH QSV Board, starting June 2024. Information presented at the WPH QSV Board will be presented to the Network Board of Directors.

482.23(b)(7) STANDARD RN POLICY FOR OUTPATIENT DEPTS:Not Assigned
The hospital must have policies and procedures in place establishing which outpatient departments, if any, are not required under hospital policy to have a registered nurse present. The policies and procedures must:
(i) Establish the criteria such outpatient departments must meet, taking into account the types of services delivered, the general level of acuity of patients served by the department, and the established standards of practice for the services delivered;
(ii) Establish alternative staffing plans;
(iii) Be approved by the director of nursing;
(iv) Be reviewed at least once every 3 years
Observations:



Based on interview (EMP), it was determined the facility failed to have policies and procedures in place establishing which outpatient departments, if any, are not required under hospital policy to have a registered nurse present.


Findings include:


During a facility survey on April 3, 2024, the facility was unable provide policies and procedures addressing which outpatient departments, if any, are not required under hospital policy to have a registered nurse present.


The above was confirmed with EMP1 on April 3, 2024, at 11:25 AM.








 Plan of Correction - To be completed: 06/01/2024

West Penn Hospital will develop an RN policy for which outpatient departments, if any, are not required to have a registered nurse present by May 30th.
Director of Nursing will review the policy with the outpatient department directors.
The policy will be approved by Director of Nursing and then published on our internal policy website by June 1st, with a renewal date of less than 3 years from published date.
The Manager of Regulatory Readiness, or their designee, will report the new policy implementation to the Performance Improvement Oversight Committee (PIOC) monthly and the WPH QSV Board, starting June 2024. Information presented at the WPH QSV Board will be presented to the Network Board of Directors.

482.23(b)(6) STANDARD SUPERVISION OF CONTRACT STAFF:Not Assigned
All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer).
Observations:



Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined licensed nurses providing services in the facility failed to document patient hand-off communication per facility policy for 13 of 20 medical records reviewed (MR1, MR2, MR4, MR5, MR6, MR8, MR9, MR11, MR13, MR16, MR18, MR19, and MR20)


Findings include:


Review of facility policy, "Patient Hand-Off Communication", last approved 6/8/2022, revealed: " ... Overview Statement ... Current, accurate information related to a patient's care, treatment/services and clinical status will be communicated when transferring the care of a patient between or among members of the heath care team/providers. ... Administration A. Intra-departmental Communication 1. Change of shift report or when care is temporarily assigned to another licensed nurse within the patient care unit. ...".


Review of MR1 revealed no evidence of patient hand-off communication on February 25, 2024, at 7:00 AM.


Review of MR2 revealed no evidence of patient hand-off communication on March 30, 2024, at 7:00 PM.


Review of MR4 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 AM.


Review of MR5 revealed no evidence of patient hand-off communication on March 25, 2024, at 7:00 AM, and on March 29, 2024, at 7:00 AM.


Review of MR6 revealed no evidence of patient hand-off communication on the following dates and times:
March 29, 2024 at 7:00 AM
March 30, 2024 at 7:00 PM
April 1, 2024 at 7:00 AM
April 2, 2024 at 7:00 AM


Review of MR8 revealed no evidence of patient hand-off communication on the following dates and times:
March 31, 2024 at 7:00 AM
April 1, 2024 at 7:00 PM
April 2, 2024 at 7:00 AM
April 3, 2024 at 7:00 AM


Review of MR9 revealed no evidence of patient hand-off communicaton on the following dates and times:
March 27, 2024 at 7:00 AM
April 2, 2024 at 7:00 AM and 7:00 PM
April 3, 2024 at 7:00 AM


Review of MR11 revealed no evidence of patient hand-off communication on the following dates and times:
March 26, 2024 at 7:00 PM
March 27, 2024 at 7:00 AM
March 28, 2024 at 7:00 PM


Review of MR13 revealed no evidence of patient hand-off communication on March 24, 2024, at 7:00 AM.


Review of MR16 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 AM and at 7:00 PM.


Review of MR18 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 PM


Review of MR19 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 AM and 7:00 PM.


Review of MR20 revealed no evidence of patient hand-off communication on April 1, 2024, at 7:00PM.


The above findings for MR1, MR2, MR4, MR5, MR6 and MR8 were confirmed during medical record review with EMP4 on April 3, 2024, between 12:00 PM and 1:50 PM.


The above findings for MR9, MR11, MR13, MR16, MR18, MR19, and MR20 were confirmed during medical record review with EMP5 on April 3, 2024, between 12:10 PM and 1:40 PM.
--------------------------------------------------------

Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined licensed nurses providing services in the facility failed to document purposeful hourly rounding per facility policy for 13 of 20 medical records reviewed (MR1, MR6, MR8, MR9, MR10, MR11, MR13, MR14, MR15, MR17, MR18, MR19 and MR20).


Findings include:


Review of facility's "Purposeful Hourly Rounds", last approved 7/31/2023, revealed: " ... The purpose of this policy is provide guidelines for patient care needs that are to be addressed during hourly rounds. ... The RN/GN/LPN/PCTs will: 1. Perform rounds on each patient a. Every 1 hour between the hours of 7am - 11pm b. Every 2 hours between the hours of 12am - 7am. ... 3. Documentation of hourly rounds occurs in the EMR. ...".


Review of MR1 revealed hourly rounds were not documented on February 25, 2024, between 9:00 PM and 7:00 AM.


Review of MR6 revealed hourly rounds were not documented on the following dates and times:
March 31, 2024 at 1:00 AM and 3:00 AM
April 1, 2024 at 1:00 PM, 3:00 PM, 4:00 PM, and 5:00 PM
April 2, 2024 at 3:00 AM, 4:00 PM and 5:00 PM


Review of MR8 revealed hourly rounds were not documented on the following dates and times:
April 2, 2024 between 10:00 AM and 5:00 PM
April 1, 2024 between 10:00 AM and 3:00 PM
March 31, 2024, between 11:00 AM and 2:00 PM


Review of MR9 revealed hourly rounds were not documented on the following dates and times:
March 27, 2024 between 11:00 AM and 4:00 PM
March 28, 2024 between 10:00 AM and 3:00 PM.
March 28, 2024 at 5:00 PM and 6:00 PM.


Review of MR10 revealed hourly rounds were not documented on the following dates and times:
March 30, 2024: 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM., 08:00 AM, 9:00 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 6:00 PM, 9:00 PM, 10:00 PM, and 11:00 PM.
March 31, 2024: 12:00 AM, 2:00 AM, 4:00 AM, 9:00 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, 6:00 PM, 9:00 PM, and 10:00 PM.


Review of MR11 revealed hourly rounds were not documented on the following dates and times:
March 27, 2024 at 2:00 PM
March 28, 2024: 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, and 6:00 PM.


Review of MR13 revealed hourly rounds were not documented on the following dates and times:
March 24, 2024: 09:00AM, 09:00 PM, 10:00 PM, and 11:00PM
March 25, 2024: 12:00 AM, 2:00 AM, 4:00 AM, 8:00 PM, 10:00 PM, and 11:00 PM
March 26, 2024: 10:00 PM


Review of MR14 revealed hourly rounds were not documented at the following times:
March 22, 2024 at 2:00 AM, 4:00 AM, 7:00 AM, 9:00 AM, 10:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM; 5:00 PM, 6:00 PM, 7:00 PM, 8:00 PM, 9:00 PM, and 11:00 PM.


Review of MR15 revealed hourly rounds were not documented at the following times: April 2, 2024 at 8:00 AM, 9:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00PM, 4;00 PM, 5:00 PM, and 6:00 PM.


Review of MR17 revealed that every two hour rounds were not documented at the following times: March 27, 2024 at 12:00 AM, 2:00 AM, 4:00 AM, and 6:00 AM. .


Review of MR18 revealed hourly rounds were not documented at the following times: April 2, 2024, at 2:00 PM, 3:00PM, 4;00 PM, 5:00 PM, 10:00 PM, and 11:00 PM.


Review of MR19 revealed hourly rounds were not documented at the following times: April 2, 2024, at 07:00 AM, 8:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 3:00PM, 4:00 PM, 5:00 PM, and 6:00 PM.


Review of MR20 revealed hourly rounds were not documented at the following times: April 1, 2024, at 9:00 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00PM, 4;00 PM, 6:00 PM and 11:00 PM.


The above findings for MR1, MR6 and MR8 were confirmed during medical record review with EMP4 on April 3, 2024 between 12:00 PM and 1:50 PM.


The above findings for MR9, MR10, MR11, MR13, MR14, MR15, MR17, MR18, MR19 and MR20 were confirmed during medical record review with EMP5 on April 3, 2024 between 12:15 PM and 1:40PM.






















 Plan of Correction - To be completed: 06/01/2024

Rehab nursing personnel on the Rehab unit will be re-educated to the nursing responsibilities of the Patient Hand off Communication and Purposeful Hourly Rounding policies by June 1st.
Rehab nurse Manager/designee will audit 10 Rehab patient records weekly for 3 months to ensure patient hand off communication and purposeful hourly rounding has occurred. Audits will begin in June 2024 and continue until compliance with all components is 90% for three (3) consecutive months to ensure that the education was effective.
The Manager of Regulatory Readiness, or their designee, will report the results of the audits to the Performance Improvement Oversight Committee (PIOC) monthly and the WPH QSV Board, starting June 2024. Information presented at the WPH QSV Board will be presented to the Network Board of Directors.

109.23 (b)(1-5) LICENSURE WRITTEN NURSING CARE POLICIES:State only Deficiency.
109.23
(b) Nursing care policies and procedures shall be consistent with professionally recognized standards of nursing practice and shall be in accordance with the Professional Nursing Law and regulations promulgated by the State Board of examiners. These policies shall include procedures for the following:
(1) noting diagnostic and therapeutic orders
(2) assigning the nursing care of patients
(3) infection control
(4) patient safety
(5) implementing orders for medication and treatment, consistent with 107.61-107.65 of this subpart.
Observations:


Based on a review of facility documentation, medical records (MR), and staff interviews (EMP) it was determined the facility failed to provide evidence in the medical record that a registered nurse (licensed professional nurse) supervised and evaluated nursing care provided by the licensed practical nurse, consistent with professionally recognized standards of nursing practice, for 4 of 20 medical records reviewed. (MR1, MR2, MR7, and MR9)


Findings include:

On April 3, 2024, review of facility policy, POL 6511361, "Licensed Practical Nurse (LPN) Role ", last approved September 26, 2023, revealed: " ... It is the policy that AHN utilizes and allows the Licensed Practical Nurse (LPN) to function as a member of the health care team ... The LPN may participate in planning, implementation, and evaluation of nursing care using focused assessment in settings where nursing takes place. ...". Further review of this policy revealed: "... Terms and Definitions: Focused assessment - Appraisal of an individual's current status and situation, which contributes to [the] comprehensive assessment by the licensed professional nurse and supports ongoing data collection. ...".


Review of MR1 revealed that the patient was cared for by a licensed practical nurse (EMP6) between February 25, 2024, at 7:00 PM, and February 26, 2024, at 7:00 AM. Further review of MR1 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during this shift.


Review of MR2 revealed that the patient was cared for by a licensed practical nurse (EMP11) between March 30, 2024, at 7:00 PM, and March 31, 2024, at 7:00 AM. Further review of MR2 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during this shift.


Review of MR7 revealed that the patient was cared for by a licensed practical nurse (EMP11) between March 28, 2024, at 7:00 AM, and March 28, 2024, at 7:00 PM. Further review of MR7 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during this shift.


Review of MR9 revealed that the patient was cared for by a licensed practical nurse (EMP11) on March 27, 2024 and March 28, 2024 from 7:00 AM to 7:00 PM. Further review of MR9 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during the shifts(s).


The above findings were confirmed for MR1, MR2, and MR7 during MR review with EMP4 on April 3, 2024, between 12:00 PM and 1:50 PM.


The above finding for MR9 was confirmed on April 3, 2024, during MR review with EMP5 on April 3, 2024, at 12:21 PM.












 Plan of Correction - To be completed: 06/01/2024

Licensed Practical Nurse (LPN) Role Policy will be revised to include the requirements of a Registered Nurse to supervise nursing care where an LPN is assigned a patient by May 21st.
RN's and LPN's will be educated to the new policy and procedure on Units where LPN's are assigned to a patient care assignment by June 1st.
Rehab Nurse Manager/designee will audit 5 rehab patient charts, weekly for 3 months, on the Rehab unit where an LPN is assigned patients to ensure RN supervision of nursing care during the shift by an RN has occurred. Audits will begin in June 2024 and continue until compliance with all components is 100% for three (3) consecutive months to ensure that the education was effective.
The Manager of Regulatory Readiness, or their designee, will report the results of the audits to the Performance Improvement Oversight Committee (PIOC) monthly and the WPH QSV Board, starting June 2024. Information presented at the WPH QSV Board will be presented to the Network Board of Directors.

109.36 LICENSURE NURSING NOTES:State only Deficiency.
109.36 Nursing notes

Nursing records and reports which reflect the progress of each patient and the nursing care planned shall be maintained. They shall be pertinent, accurate, and concise so that they contribute to the continuity of patient care. Nursing records and reports shall become part of each patient's medical record.
Observations:


Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined nursing records and reports failed to provide evidence of patient hand-off communication per facility policy for 13 of 20 medical records reviewed (MR1, MR2, MR4, MR5, MR6, MR8, MR9, MR11, MR13, MR16, MR18, MR19, and MR20)


Findings include:


Review of facility policy, "Patient Hand-Off Communication", last approved 6/8/2022, revealed: " ... Overview Statement ... Current, accurate information related to a patient's care, treatment/services and clinical status will be communicated when transferring the care of a patient between or among members of the heath care team/providers. ... Administration A. Intra-departmental Communication 1. Change of shift report or when care is temporarily assigned to another licensed nurse within the patient care unit. ...".


Review of MR1 revealed no evidence of patient hand-off communication on February 25, 2024, at 7:00 AM.


Review of MR2 revealed no evidence of patient hand-off communication on March 30, 2024, at 7:00 PM.


Review of MR4 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 AM.


Review of MR5 revealed no evidence of patient hand-off communication on March 25, 2024, at 7:00 AM, and on March 29, 2024, at 7:00 AM.


Review of MR6 revealed no evidence of patient hand-off communication on the following dates and times:
March 29, 2024 at 7:00 AM
March 30, 2024 at 7:00 PM
April 1, 2024 at 7:00 AM
April 2, 2024 at 7:00 AM


Review of MR8 revealed no evidence of patient hand-off communication on the following dates and times:
March 31, 2024 at 7:00 AM
April 1, 2024 at 7:00 PM
April 2, 2024 at 7:00 AM
April 3, 2024 at 7:00 AM


Review of MR9 revealed no evidence of patient hand-off communicaton on the following dates and times:
March 27, 2024 at 7:00 AM
April 2, 2024 at 7:00 AM and 7:00 PM
April 3, 2024 at 7:00 AM


Review of MR11 revealed no evidence of patient hand-off communication on the following dates and times:
March 26, 2024 at 7:00 PM
March 27, 2024 at 7:00 AM
March 28, 2024 at 7:00 PM


Review of MR13 revealed no evidence of patient hand-off communication on March 24, 2024, at 7:00 AM.


Review of MR16 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 AM and at 7:00 PM.


Review of MR18 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 PM


Review of MR19 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 AM and 7:00 PM.


Review of MR20 revealed no evidence of patient hand-off communication on April 1, 2024, at 7:00PM.


The above findings for MR1, MR2, MR4, MR5, MR6 and MR8 were confirmed during medical record review with EMP4 on April 3, 2024, between 12:00 PM and 1:50 PM.


The above findings for MR9, MR11, MR13, MR16, MR18, MR19, and MR20 were confirmed during medical record review with EMP5 on April 3, 2024, between 12:10 PM and 1:40 PM.

--------------------------------------------------------


Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined facility nursing records failed to document evidence of purposeful hourly rounding per facility policy for 13 of 20 medical records reviewed (MR1, MR6, MR8, MR9, MR10, MR11, MR13, MR14, MR15, MR17, MR18, MR19 and MR20).


Findings include:


Review of facility's "Purposeful Hourly Rounds", last approved 7/31/2023, revealed: " ... The purpose of this policy is provide guidelines for patient care needs that are to be addressed during hourly rounds. ... The RN/GN/LPN/PCTs will: 1. Perform rounds on each patient a. Every 1 hour between the hours of 7am - 11pm b. Every 2 hours between the hours of 12am - 7am. ... 3. Documentation of hourly rounds occurs in the EMR. ...".


Review of MR1 revealed hourly rounds were not documented on February 25, 2024, between 9:00 PM and 7:00 AM.


Review of MR6 revealed hourly rounds were not documented on the following dates and times:
March 31, 2024 at 1:00 AM and 3:00 AM
April 1, 2024 at 1:00 PM, 3:00 PM, 4:00 PM, and 5:00 PM
April 2, 2024 at 3:00 AM, 4:00 PM and 5:00 PM


Review of MR8 revealed hourly rounds were not documented on the following dates and times:
April 2, 2024 between 10:00 AM and 5:00 PM
April 1, 2024 between 10:00 AM and 3:00 PM
March 31, 2024, between 11:00 AM and 2:00 PM


Review of MR9 revealed hourly rounds were not documented on the following dates and times:
March 27, 2024 between 11:00 AM and 4:00 PM
March 28, 2024 between 10:00 AM and 3:00 PM.
March 28, 2024 at 5:00 PM and 6:00 PM.


Review of MR10 revealed hourly rounds were not documented on the following dates and times:
March 30, 2024: 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM., 08:00 AM, 9:00 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 6:00 PM, 9:00 PM, 10:00 PM, and 11:00 PM.
March 31, 2024: 12:00 AM, 2:00 AM, 4:00 AM, 9:00 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, 6:00 PM, 9:00 PM, and 10:00 PM.


Review of MR11 revealed hourly rounds were not documented on the following dates and times:
March 27, 2024 at 2:00 PM
March 28, 2024: 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, and 6:00 PM.


Review of MR13 revealed hourly rounds were not documented on the following dates and times:
March 24, 2024: 09:00AM, 09:00 PM, 10:00 PM, and 11:00PM
March 25, 2024: 12:00 AM, 2:00 AM, 4:00 AM, 8:00 PM, 10:00 PM, and 11:00 PM
March 26, 2024: 10:00 PM


Review of MR14 revealed hourly rounds were not documented at the following times:
March 22, 2024 at 2:00 AM, 4:00 AM, 7:00 AM, 9:00 AM, 10:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM; 5:00 PM, 6:00 PM, 7:00 PM, 8:00 PM, 9:00 PM, and 11:00 PM.


Review of MR15 revealed hourly rounds were not documented at the following times: April 2, 2024 at 8:00 AM, 9:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00PM, 4;00 PM, 5:00 PM, and 6:00 PM.


Review of MR17 revealed that every two hour rounds were not documented at the following times: March 27, 2024 at 12:00 AM, 2:00 AM, 4:00 AM, and 6:00 AM. .


Review of MR18 revealed hourly rounds were not documented at the following times: April 2, 2024, at 2:00 PM, 3:00PM, 4;00 PM, 5:00 PM, 10:00 PM, and 11:00 PM.


Review of MR19 revealed hourly rounds were not documented at the following times: April 2, 2024, at 07:00 AM, 8:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 3:00PM, 4:00 PM, 5:00 PM, and 6:00 PM.


Review of MR20 revealed hourly rounds were not documented at the following times: April 1, 2024, at 9:00 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00PM, 4;00 PM, 6:00 PM and 11:00 PM.


The above findings for MR1, MR6 and MR8 were confirmed during medical record review with EMP4 on April 3, 2024 between 12:00 PM and 1:50 PM.


The above findings for MR9, MR10, MR11, MR13, MR14, MR15, MR17, MR18, MR19 and MR20 were confirmed during medical record review with EMP5 on April 3, 2024 between 12:15 PM and 1:40PM.







 Plan of Correction - To be completed: 06/01/2024

Rehab nursing personnel on the Rehab unit will be re-educated to the nursing responsibilities of the Patient Hand off Communication and Purposeful Hourly Rounding policies by June 1st.
Rehab nurse Manager/designee will audit 10 rehab patient charts per week for 3 months to ensure patient hand off communication and purposeful hourly rounding has occurred. Audits will begin in June 2024 and continue until compliance with all components is 90% for three (3) consecutive months to ensure that the education was effective.
The Manager of Regulatory Readiness, or their designee, will report the results of the audits to the Performance Improvement Oversight Committee (PIOC) monthly and the WPH QSV Board, starting June 2024. Information presented at the WPH QSV Board will be presented to the Network Board of Directors.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port