Nursing Investigation Results -

Pennsylvania Department of Health
LEHIGH VALLEY HOSPITAL-SCHUYLKILL
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LEHIGH VALLEY HOSPITAL-SCHUYLKILL
Inspection Results For:

There are  165 surveys for this facility. Please select a date to view the survey results.

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LEHIGH VALLEY HOSPITAL-SCHUYLKILL - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

This report is the result of unannounced onsite complaint investigations (WIL20C000I and CHL20C058I), completed on February 19, 20, 21 and 27, 2020, at Lehigh Valley Hospital - Schuylkill. 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:


Initial comments:
This report is the result of unannounced onsite complaint investigations (WIL20C000I and CHL20C058I), conducted on February 19, 20, 21 and 27, 2020, at Lehigh Valley Hospital - Schuylkill. 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.



 Plan of Correction:


482.13(e)(5) STANDARD PATIENT RIGHTS: RESTRAINT OR SECLUSION:Not Assigned
482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law.
Observations:
Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to have a physician order for restraint of one of four applicable medical records reviewed (MR9).

Findings include:

Review on February 20, 2020, of the facility policy "Patient Rights and Responsibilities," last reviewed February 13, 2020, revealed "... II. Policy: All patients should receive quality health care, according to need, regardless of race, age, ethnicity, religion, sex, sexual orientation, culture, language, physical or mental disability, socioeconomic status, and gender identity or expression. Patients will be treated as individuals, and the medical center recognizes their very unique needs and desires and strives to meet their needs to the best of our ability ... A Statement of Patient Rights ... Care Delivery ... Receive care free from restraints or seclusion unless necessary to provide medical, surgical or behavioral health care ..."

Review on February 20, 2020, of the facility policy "Restraint and Seclusion Policy," last reviewed August 23, 2019, revealed "II. Policy: The policy and practice associated with the use of restraint, seclusion and restraint and seclusion at Lehigh Valley Hospital - Schuylkill are designed to maintain the rights, dignity, and wellbeing of our patients, are committed to the prevention, reduction and elimination of restraint and/or seclusion and are fully supported by organizational leadership. When clinically appropriate in adequately justified situations and after all other non-physical alternatives have been exhausted the least restrictive method of restraint that meets the needs of the patient will be applied following an assessment by a qualified RN, qualified Physician Assistant (PA) or Licensed Independent Practitioner (LIP) ... III. Definitions: ... 9. Physical / Therapeutic Hold: The intentional physical holding down of a patient for care or treatment purposes such as administration of medication for agitation will be deemed a restraint and as such will require an order by an [sic] LIP for use of Physical Hold ... IV. Procedure: 1. Non-Violent/Non-Self Destructive A. Restraint Alternatives ... 2). If restraint alternatives are unsuccessful, the RN must reassess the patient, paying particular attention t the special needs of vulnerable patient populations such as emergency, pediatric and cognitively or physically limited patients to determine whether or not clinical justification for application of a restraint exists ... C. Restraint Orders: 1). A physician order is required for all patient restraints. a.) The use of restraint must be in accordance with the order from a physician or other LIP who is responsible for the care of the patient and who is authorized to order restraint or seclusion ..."

Review of MR9 on February 21, 2020, revealed this patient was seen in the Emergency Department (ED) on January 21, 2020, for treatment of a laceration of the head. A progress note indicated the patient was autistic and very difficult to hold still. Five staff members and a family member physically held the patient while the laceration was being stapled. Further review of MR9 revealed no order for the physical hold of this patient.

Interview with EMP5, at 10:40 AM, on February 21, 2020, confirmed there was no order for the physical hold of MR9.

Interview with CF2, at 9:00 AM, on February 21, 2020, revealed they were working the day MR9 was seen in the ED. CF2 confirmed MR9 was held down by multiple staff to complete the stapling of the patient's laceration. CF2 confirmed there was no order to physically hold MR9 for this procedure.


Repeat citation July 25, 2019.




 Plan of Correction - To be completed: 04/05/2020

1. The Restraint and Seclusion for Violent/Self-Destructive Behavior and Restraint for Non Self -Destructive Behavior policies last approved 10/14/19 were in effect on 1/21/2020. The policies define approved types of physical restraint devices for patients who meet criteria and standardize the requirements of obtaining appropriate restraint orders when less restrictive interventions have been determined to be ineffective.

2. The Emergency Department Provider and Nursing staff will be reeducated on the use of appropriate physical restraint to provide safe care to patients according to policy by 3/30/2020. The education will be led by the Vice Chair Department of Emergency Medicine & Hospital Medicine.

3. The Regional Chief Medical Officer will reinforce education on the policy Restraint and Seclusion via memo to providers in the Emergency Department by 4/3/20.

4. Beginning 4/1/2020, a weekly audit of ten randomized medical records for patients presenting to the emergency department with head injury will be completed by Quality Department/Designee to ensure that all patients who require intervention receive care according to the direction of the restraint policies. Documentation of care including the required restraint orders per policy will be counted. Any area of non-compliance will be addressed by the Regional Chief Medical Officer/Vice Chair Department of Emergency Medicine to include re-education. The chart audits will continue for 3 months. At that time, the need for further chart reviews will be assessed.

5. Audit results will be forwarded to the Chair Department of Emergency and Hospital Medicine. In addition, the results will be reported to the Network Quality & Patient Safety Council and the CNO Council on a monthly basis, beginning in May 2020.

6. The Regional Chief Medical Officer is responsible for the implementation of and ongoing compliance with this plan of correction.

482.55(a)(3) STANDARD EMERGENCY SERVICES POLICIES:Not Assigned
[If emergency services are provided at the hospital --]

(3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff.

Observations:

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to adopt a policy that defined procedure requirements and expectations for patients presenting to the Emergency Department (ED) with head injuries.

Findings include:

Review on February 20, 2020, of the Emergency Department (ED) Policy and Procedure Manuel revealed no policy for care of a patient with a head injury.

Interview with CF2, at 9:00 AM, on February 21, 2020, confirmed the hospital's medical staff had not developed policies and procedures governing the medical care to be provided to patients presenting to the ED with head injuries.

Review on February 19, 2020, of the ED log for January 6, 7, 8, 20, 21, 2020, revealed 13 patients presented to the ED with head injuries on those days.

Cross reference
Tag 0347 - 482.22(b)(1)(2)(3) Medical Staff Organization and Accountability








 Plan of Correction - To be completed: 04/05/2020

1. A clinical protocol for pediatric head injury, last updated 3/15/19, provides an algorithm for providers on consistent evaluation and documentation of care for pediatric patients presenting to the Emergency Department within 24 hours of head injury. Additionally, the algorithm standardizes provision of discharge education and is cognizant of unnecessary radiation exposure. An Emergency Department algorithm for adult head injury will be developed by the Vice Chair Department of Emergency and Hospital Medicine by March 23, 2020. The algorithm will guide the emergency department providers on the consistent evaluation and documentation of care, including provision of appropriate discharge instructions, for adult patients presenting to the Emergency Department with head injuries. The practice of the Emergency Department has been to perform CT imaging on patients over the age of 70 that present with head injury, which was confirmed during survey chart review and stated in deficiency report.

2. Physicians and Advanced Practice Professionals in the Emergency Department will receive education on the new algorithm for adult head injury, inclusive of the use and documentation of appropriate discharge instructions for patients with head injury by March 31, 2020 by the Vice Chair Department of Emergency and Hospital Medicine.

3. Beginning April 5, 2020 a weekly audit of ten medical records for all patients that present to the emergency department for a diagnosis of a head injury will be completed by Quality Department/Designee to ensure that all patients receiving treatment for a head injury were evaluated and received care based on the algorithm and were provided appropriate discharge instructions for head injury. Any non-compliance will be addressed by the Regional Chief Medical Officer and/or Vice Chair Department of Emergency and Hospital Medicine to include re-education. The chart audits will continue for 3 months. At that time, the need for further chart reviews will be assessed.

4. Audit results will be forwarded to the Chair Department of Emergency Medicine and Hospital Medicine and Regional Chief Medical Officer. In addition, the results will be reported to the Network Quality & Patient Safety Council on a monthly basis, beginning in May 2020 and the Professional Care Committee quarterly beginning May 2020.

5. The Regional Chief Medical Officer is responsible for the implementation of and ongoing compliance with this plan of correction.



482.24(c)(4)(v) STANDARD CONTENT OF RECORD: INFORMED CONSENT:Not Assigned
[All records must document the following, as appropriate:]
Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent.


Observations:
Based on facility documents, medical record (MR) review and staff (EMP) interview, it was determined the facility failed to ensure documentation of the verbal consent for treatment obtained via telephone included the name of the person giving the consent, their relationship to the patient, and the reason the written consent could not be obtained for two of 12 medical records reviewed (MR1 and MR5).

Findings include:

Review on February 21, 2020, of facility "Consent For Treatment - General," last reviewed August 26, 2019, revealed "...II. Policy: Policy Statement: Upon arrival to the hospital, the patient will be asked to sign a consent form for general treatment before such treatment can be initiated. Everyone eighteen (18) years of age or older, being of sound mind, had the right to decide whether to consent to medical diagnosis and treatment. III. Definitions: Incompetent - a condition in which an individual despite being provided appropriate medical information, communication supports, and technical assistance, is documented by a health care provider to be unable to understand the potential material benefits, risks, and alternatives involved in a specific proposed health care decision; unable to make that health care decision on his own behalf; or unable to communicate that health care decision to any other person. IV. Procedure: Guidelines: ... 6. In unusual circumstances when consent cannot be obtained in writing, in a timely manner, consent may be obtained by telephone. The telephone conversation shall be witnessed by an individual other than the individual obtaining the consent. The witness to the consent shall be identified to the person giving consent. The person giving consent shall be identified by name and relationship to the patient in the patient's medical record along with the reason why written consent could not be obtained and the nature of the consent obtained ..."

Review on February 19, 2020, of MR1 revealed the patient was nonverbal and accompanied to the ED by a caregiver from the patient's group home. The Consent for Treatment revealed documentation of verbal consent by telephone. There was no documentation of the name of the person giving the verbal consent, their relationship to the patient and the reason written consent could not be obtained.

Interview with EMP1 on February 20, 2020, at 2:40 PM, confirmed the Consent for Treatment for MR1 was a verbal consent received by telephone; there was no documentation of the name of the person giving the verbal consent, their relationship to the patient and the reason written consent could not be obtained.

Review on February 19, 2020, of MR5 revealed the patient was nonverbal. The Consent for Treatment revealed documentation of verbal consent by telephone. There was no documentation of the name of the person giving the verbal consent, their relationship to the patient and the reason written consent could not be obtained.

Interview with EMP1 on February 20, 2020, at 2:40 PM, confirmed the Consent for Treatment for MR5 was a verbal consent received by telephone; there was no documentation of the name of the person giving the verbal consent, their relationship to the patient and the reason written consent could not be obtained.




 Plan of Correction - To be completed: 04/05/2020

1. Registration staff will be educated by the Director of Registration and/or Supervisor of Registration on policy 'Consent to Treat, General' by March 20, 2020. The education includes the verbal consent process, which requires documentation in the medical record of the following for any verbal consent received by telephone: documentation of the name of the person giving the verbal consent, the individual's relationship to the patient and the reason a written consent could not be obtained.
2. Beginning March 23, 2020, a weekly audit of twenty medical records for emergency department patients will be reviewed by Director of Registration/Designee to ensure that any verbal consent received by telephone contains the three documentation requirements as stated in policy. Any area of non-compliance will be addressed by the Director of Registration/Registration Supervisor with the staff member to include re-education. The chart audits will continue for 3 months. At that time, the need for further chart reviews will be assessed.
3. Audit results will be forwarded to the Quality Department. In addition, the results will be reported to the Network Quality & Patient Safety Council and CNO Council on a monthly basis, beginning in April 2020 and the Professional Care Committee quarterly beginning May 2020.
4. The Director of Registration is responsible for the implementation of and ongoing compliance with this plan of correction.

482.22(b)(1), (2), (3) STANDARD MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY:Not Assigned
The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients.

(1) The medical staff must be organized in a manner approved by the governing body.

(2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy.

(3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following:
(i) An individual doctor of medicine or osteopathy.
(ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located.
(iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located.


Observations:

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the medical staff failed to adopt a policy that defined the expectations for evaluation, treatment and discharge instruction of patients presenting to the Emergency Department (ED) with head injuries, resulting in inconsistent treatment to patients with head injuries for 12 of 12 pertinent medical records reviewed (MR1 through MR12).

Findings include:

A review on February 20, 2020, of the "Amended and Restated Bylaws Schuylkill Medical Center-South Jackson Street," last reviewed November 2019, revealed "... Article VIII. Medical Staff Section 1. Medical Staff. The Board shall appoint an organized medical staff (the "Medical Staff") for the Hospital which shall operate in accordance with Medical Staff Bylaws ("Staff Bylaws") which shall be approved by the Board and by the Sole Member. The Medical Staff shall operate as an integral part of the Hospital and through its committees and Officers, shall be responsible for and accountable to the Board for the quality of medical care provided to patients of the Hospital ..."

Review of the "Medical Staff Rules and Regulations," last reviewed November 18, 2019, revealed "Introduction a. These Medical Staff Rules and Regulations are parameters for the conduct of professional clinical activities at the Hospital ... F. Emergency Department ... 3. Every patient presenting to the Emergency Department for care must be examined by a credentialed member of the Medical Staff, the Resident Staff, or the Allied Health Professional Staff ... 13. Diagnostic tests will be done in the Emergency Department when necessary for timely diagnosis and treatment ... H. Records ... 2. (d.) Emergency Department Records ... For an emergency patient, documentation of patient's evaluation, diagnosis and treatment along with discharge instructions, will be the responsibility of the Medical Staff Member caring for the patient ..."

Review on February 21, 2020, of facility "Discharge of Patients From the Emergency Department - Emergency Medicine," last reviewed October 9, 2019, revealed "... II. Policy: To assure a consistent process of discharge of emergency department patients. All patients discharged from the emergency department will have an appropriate follow-up plan of care discussed with them prior to discharge. ... IV. Procedure: ... 3. Discuss discharge instructions and plan with patient and/or appropriate responsible parties. ... 7. Give copy of discharge instructions and al prescriptions as indicated to the patient/family ..."

Review on February 19, 2020, of MR1 revealed this 59-year-old patient was seen in the ED on January 7, 2020, for injuries sustained in a fall downstairs. The patient sustained a laceration to the right outer ear and an abrasion to the right parietal scalp area. The patient was nonverbal and accompanied to the ED by a caregiver from the patient's group home. No computerized tomography (CT) scans or x-rays were completed. The laceration was cleansed, and then was closed. The patient was discharged at 0729 on January 7, 2020. Discharge instructions for wound care were given. No instructions on monitoring for head injury symptoms were given on discharge.

Review of MR1's medical record from an outside hospital revealed this patient required examination in another Emergency Department at 1224 on January 8, 2020. The patient had symptoms of stumbling, not moving head as normal and signs of pain. CT scans of the head and cervical spine were completed, and the patient was diagnosed with a subdural hematoma and a fracture of the cervical spine. The patient required transfer to a trauma center on January 8, 2020, for further treatment.

Review on February 19, 2020, of MR2 revealed this 76-year-old patient was seen in the ED on January 6, 2020, for an injury to the head, after a fall. This patient was verbal and complained of back pain and dizziness. No open skin areas were noted. CT scans of the head and lumbar spine were completed. Discharge instructions were given for fall prevention. No instruction to observe for neurological changes were given on discharge.

Review on February 19, 2020, of MR3 revealed this 79-year-old patient was seen in the ED on January 6, 2020, for a contusion and abrasion to the head, after a fall. This patient was verbal and offered no complaint of pain. CT scan of head was completed. Discharge instructions were given for care of a contusion. No instruction to observe for neurological changes were given on discharge.

Review on February 19, 2020, of MR4 revealed this 4-year-old patient was seen in the ED on January 6, 2020, with a head laceration, after a fall. The patient was verbal. No imaging studies were completed. Discharge instructions for care of a child with a minor head injury were given [won't stop crying, becomes very sleepy, complains of dizziness, becomes restless or confused, complains of head or neck pain or stiffness or vomits].

Review on February 19, 2020, of MR5 revealed this 73-year-old patient was seen in the ED on January 7, 2020, with a scalp abrasion, after a fall out of bed. This patient was non-verbal. No caregiver from the patient's group home accompanied this patient. CT scans of head and cervical spine were completed. Discharge instructions were given for care of an abrasion. No instruction to observe for neurological changes were given on discharge.

Review on February 20, 2020, of MR6 revealed this 41-year-old patient was seen in the ED on January 7, 2020, for a laceration of the head. Patient hit self on the head with a guitar. This patient was alert and verbal. The laceration was closed after application of a local anesthetic. No CT scan or x-ray were completed. Patient left the ED without their discharge instructions.

Review on February 20, 2020, of MR7 revealed this 48-year-old patient was seen in the ED on January 20, 2020, for a contusion to the head following a fall and hitting head and back on concrete. This patient was verbal. Pain medication was given to this patient. CT of the spine and head were completed. Discharge instructions were for care of a contusion. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR8 revealed this 80-year-old patient was seen in the ED on January 20, 2020, for an eyebrow laceration sustained in a fall. This patient was verbal and reported no loss of consciousness. The laceration was repaired. CT of the spine and head were completed. Discharge instructions for care of the laceration were given. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR9 revealed this 20-year-old patient was seen in the ED on January 21, 2020, for a laceration to the head. This patient was non-verbal. Family was unsure if patient sustained the injury in a fall. The laceration was closed with staples after being cleansed. An attempt to apply an anesthetic to the area was made. A progress note indicated the patient was autistic and very difficult to hold still. Five staff members and a family member physically held the patient while the laceration was being stapled. Discharge instructions for care of the laceration were given. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR10 revealed this 3-year-old patient was seen in the ED on January 21, 2020, for a laceration of the ear following a fall from a bed. Family reported the patient hit their head on a dresser. The ear laceration was closed with sutures after application of a local anesthetic. No CT scan or x-rays studies were completed. Discharge instructions for care of the laceration were given. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR11 revealed this 41-year-old patient was seen in the ED on January 20, 2020, for a minor head injury from a fall. This patient was non-verbal and was accompanied to the ED by a caregiver from the patient's group home. No CT scan or x-rays were completed. Discharge instructions included monitoring for neurological changes.

Review on February 20, 2020, of MR12 revealed this 96-year-old patient was seen in the ED on January 8, 2020, for a head contusion following a fall. This patient was verbal. CT of the cervical and lumbar spine were completed. Discharge instructions were for care of a contusion. No instruction to observe for neurological changes were given.

Interview with EMP5 on February 19, 2020, at 3:15 PM, confirmed MR1 through MR5 were seen in the ED for a type of head injury. EMP5 confirmed MR2, MR3 and MR5 had CT scans of their head or spine and MR1 and MR4 did not have a CT scan of the head.
EMP5 confirmed MR4 received discharge instructions for monitoring a child with a head injury for the next 24 hours. EMP5 confirmed MR1, MR2, MR3 and MR5 did not receive instructions to monitor for neurological changes.

Interview with EMP5, at 10:40 AM, on February 20, 2010, confirmed MR6 through MR12 were seen in the ED for a type of head injury. EMP5 confirmed MR7, MR8 and MR12 had CT scans of their head and/or spine, and MR6, MR9, MR10 and MR11 did not have a CT scan or x-ray of the head or spine. EMP5 confirmed MR11 received discharge instructions to monitor the patient for neurological changes. EMP5 confirmed MR7, MR8, MR9, MR10 and MR12 did not receive instructions to monitor for neurological changes. EMP5 confirmed patients with head injuries received varying types of evaluation, treatment and discharge instruction. EMP5 confirmed the facility does not have a policy or protocol to follow for treatment of patients with head injuries.

Interview with CF2, at 9:00AM, on February 21, 2020, confirmed ED patients may receive varying treatments for their head injuries and the ED does not have a policy or protocol to follow for evaluation, treatment and discharge instruction of patients with head injuries. CF2 stated they were going to develop a head injury protocol.

Interview with EMP1 on February 21, 2020, at approximately 1:35 PM, confirmed MR1's discharge instructions did not include observation for neurological changes. EMP1 confirmed the electronic medical record system chooses the discharge instructions according to the diagnosis. If the diagnosis was listed as a laceration or a contusion, and not head injury, only the laceration or contusion discharge instruction would be generated and given to the patient.





 Plan of Correction - To be completed: 04/05/2020

1. A clinical protocol for pediatric head injury, last updated 3/15/19, provides an algorithm for providers on consistent evaluation and documentation of care for pediatric patients presenting to the Emergency Department within 24 hours of head injury. Additionally, the algorithm standardizes provision of discharge education and is cognizant of unnecessary radiation exposure. An Emergency Department algorithm for adult head injury will be developed by the Vice Chair Department of Emergency and Hospital Medicine by March 23, 2020. The algorithm will guide the emergency department providers on the consistent evaluation and documentation of care, including provision of appropriate discharge instructions, for adult patients presenting to the Emergency Department with head injuries. The practice of the Emergency Department has been to perform CT imaging on patients over the age of 70 that present with head injury, which was confirmed during survey chart review and stated in deficiency report.

2. Physicians and Advanced Practice Professionals in the Emergency Department will receive education on the new algorithm for adult head injury, inclusive of the use and documentation of appropriate discharge instructions for patients with head injury by March 31, 2020 by the Vice Chair Department of Emergency and Hospital Medicine.

3. Beginning April 5, 2020 a weekly audit of ten medical records for all patients that present to the emergency department for a diagnosis of a head injury will be completed by Quality Department/Designee to ensure that all patients receiving treatment for a head injury were evaluated and received care based on the algorithm and were provided appropriate discharge instructions for head injury. Any non-compliance will be addressed by the Regional Chief Medical Officer and/or Vice Chair Department of Emergency and Hospital Medicine to include re-education. The chart audits will continue for 3 months. At that time, the need for further chart reviews will be assessed.

4. Audit results will be forwarded to the Chair Department of Emergency Medicine and Hospital Medicine and Regional Chief Medical Officer. In addition, the results will be reported to the Network Quality & Patient Safety Council on a monthly basis, beginning in May 2020 and the Professional Care Committee quarterly beginning May 2020.

5. The Regional Chief Medical Officer is responsible for the implementation of and ongoing compliance with this plan of correction.



103.4 (3) LICENSURE FUNCTIONS:State only Deficiency.
(3) Take all reasonable steps to
conform to all applicable Federal,
State, and local laws and
regulations.
Observations:
Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to conform to all Federal and State laws.

Lehigh Valley Hospital-Schuylkill was found to be non-compliant with the following Federal regulation:

A-0168 482.13(e)(5) Standard: Restraint for acute medical and surgical care

482.13(e)(5) The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under 481.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law.

This is not met as evidenced by:

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a physician order for restraints was written for one of four applicable medical records reviewed (MR9).

Findings include:

Review on February 20, 2020, of the facility policy "Patient Rights and Responsibilities," last reviewed February 13, 2020, revealed "... II. Policy: All patients should receive quality health care, according to need, regardless of race, age, ethnicity, religion, sex, sexual orientation, culture, language, physical or mental disability, socioeconomic status, and gender identity or expression. Patients will be treated as individuals, and the medical center recognizes their very unique needs and desires and strives to meet their needs to the best of our ability ... A Statement of Patient Rights ... Care Delivery ... Receive care free from restraints or seclusion unless necessary to provide medical, surgical or behavioral health care ..."

Review on February 20, 2020, of the facility policy "Restraint and Seclusion Policy," last reviewed August 23, 2019, revealed "II. Policy: The policy and practice associated with the use of restraint, seclusion and restraint and seclusion at Lehigh Valley Hospital - Schuylkill are designed to maintain the rights, dignity, and wellbeing of our patients, are committed to the prevention, reduction and elimination of restraint and/or seclusion and are fully supported by organizational leadership. When clinically appropriate in adequately justified situations and after all other non-physical alternatives have been exhausted the least restrictive method of restraint that meets the needs of the patient will be applied following an assessment by a qualified RN, qualified Physician Assistant (PA) or Licensed Independent Practitioner (LIP) ... III. Definitions: ... 9. Physical / Therapeutic Hold: The intentional physical holding down of a patient for care or treatment purposes such as administration of medication for agitation will be deemed a restraint and as such will require an order by an [sic] LIP for use of Physical Hold ... IV. Procedure: 1. Non-Violent/Non-Self Destructive A. Restraint Alternatives ... 2). If restraint alternatives are unsuccessful, the RN must reassess the patient, paying particular attention t the special needs of vulnerable patient populations such as emergency, pediatric and cognitively or physically limited patients to determine whether or not clinical justification for application of a restraint exists ... C. Restraint Orders: 1). A physician order is required for all patient restraints. a.) The use of restraint must be in accordance with the order from a physician or other LIP who is responsible for the care of the patient and who is authorized to order restraint or seclusion ..."

Review of MR9 revealed this 20-year-old patient was seen in the Emergency Department (ED) on January 21, 2020, for treatment of a laceration of the head. A progress note indicated the patient was autistic and very difficult to hold still. Five staff members and a family member physically held the patient while the laceration was being stapled. Further review of MR9 revealed no order for the physical hold of this patient.

Interview with CF2, at 9:00 AM, on February 21, 2020, revealed they were working the day MR9 was seen in the ED. CF2 confirmed MR9 was held down by multiple staff to complete the stapling of their laceration. CF2 confirmed there was no order to physically hold MR9 for this procedure.

_____________

Lehigh Valley Hospital-Schuylkill was found to be non-compliant with the following State laws:

The Medical Care Availability and Reduction of Error Act, 40 P.S. 1303.101 et seq. 1303.308 Reporting and notification. (b) Duty to notify patient. A medical facility through an appropriate designee shall provide written notification to a patient affected by a serious event or, with the consent of the patient, to an available family member or designee, within seven days of the occurrence or discovery of a serious event. If the patient is unable to give consent, the notification shall be given to an adult member of the immediate family. If an adult member of the immediate family cannot be identified or located, notification shall be given to the closest adult family member. For unemancipated patients who are under 18 years of age, the parent or guardian shall be notified in accordance with this subsection. The notification requirements of this subsection shall not be subject to the provisions of Section 311 (a). Notification under this subsection shall not constitute an acknowledgement or admission of liability.

The Medical Care Availability and Reduction of Error Act, 40 P.S. 1303.101 et seq. 1303.313 Medical Facility reports and notifications (a) Serious event reports A medical facility shall report the occurrence of a serious event to the department and the authority within 24 hours of the medical facility's confirmation of the occurrence of the serious event. The report to the department and the authority shall be in the form and manner prescribed by the authority in consultation with the department and shall not include the name of any patient or any other identifiable individual information. The Medical Care Availability and Reduction of Error Act, 40 P.S. 1303.101 et seq. 1303.308 Reporting and notification.

This is not met as evidenced by:

Based on review of facility policy, the Department database, medical records, facility documentation and staff (EMP) interview, it was determined the facility failed to electronically report a serious event to the Department and the Patient Safety Authority within 24 hours of the occurrence in one of three medical records reviewed (MR14) and failed to provide written notification to the patient of the event for one of one applicable medical record reviewed (MR14)

Findings include:

Review on February 21, 2020, of facility policy "Patient Safety Plan," last reviewed March 2019, revealed "I. Policy It is the policy of Lehigh Valley Hospital - Schuylkill to comply with the requirements of the Pennsylvania Medical Care Availability and Reduction of Error Act ("Mcare"), 40 P.S. 1303.101, et. Seq. and the Joint Commission by creating a comprehensive Patient Safety Program. This Program shall include procedures for: ... 4) reporting Reportable Patient Occurrences to the Pennsylvania Department of Health, the Pennsylvania Patient Safety Authority and/or the Joint Commission, as appropriate. II. Definitions ... O. Serious Event: As defined by Mcare: An event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient ... V. Internal system for reporting, screening and investigating reportable patient occurrences ... B. Identification of Serious Events and Infrastructure Failures ... d. If, ... it is confirmed that the occurrence is a Serious Event or Infrastructure Failure: i. Notice of the determination of a Serious Event or Infrastructure Failure shall be forwarded immediately to the Patient safety Officer (for appropriate reporting to the appropriate department/authority) ... VII. Communications with Patients and Patient Families ... B. Lehigh Valley Hospital - Schuylkill will coordinate the process by which patients, family members and/or designees are provided written notices of the discovery of a Serious Event in compliance with Mcare. 1. All written notices to patients shall be created and communicated in the manner and form approved by the Patient Safety Committee and or its designee(s) as coordinated by the Patient Safety Officer. A. Notification shall go to the patient and an (sic) family member(s) and/or designee(s) authorized by the patient ..."

Review on February 21, 2020, of a facility document revealed a tip of a guidewire broke off into the bone of a patient during surgery. This patient record was requested.

Review on February 27, 2020, of MR14, revealed this patient had surgery on November 4, 2019, to repair a left hip fracture. Review of the operative report revealed "Complication: Retained broken fragment of the guide pin." The procedure details revealed the guidewire tip broke off into the bone. It was unable to be retrieved.

Interview with EMP1, at approximately 9:30 AM, on February 21, 2020, revealed the facility did not identify this as a serious incident, did not notify the Department of the incident and did not send a letter to the patient notifying them of the incident.

Email communication with EMP1 on February 27, 2020, revealed there was no documentation in MR14 that the physician notified the patient of this incident.






 Plan of Correction - To be completed: 04/05/2020

1. The Restraint and Seclusion for Violent/Self-Destructive Behavior and Restraint for Non Self -Destructive Behavior policies last approved 10/14/19 were in effect on 1/21/2020. The policies define approved types of physical restraint devices for patients who meet criteria and standardize the requirements of obtaining appropriate restraint orders when less restrictive interventions have been determined to be ineffective.

2. The Emergency Department Provider and Nursing staff will be reeducated on the use of appropriate physical restraint to provide safe care to patients according to policy by 3/30/2020. The education will be led by the Vice Chair Department of Emergency Medicine & Hospital Medicine.

3. The Regional Chief Medical Officer will reinforce education on the policy Restraint and Seclusion via memo to providers in the Emergency Department by 4/3/20.

4. Beginning 4/1/2020, a weekly audit of ten randomized medical records for patients presenting to the emergency department with head injury will be completed by Quality Department/Designee to ensure that all patients who require intervention receive care according to the direction of the restraint policies. Documentation of care including the required restraint orders per policy will be counted. Any area of non-compliance will be addressed by the Regional Chief Medical Officer/Vice Chair Department of Emergency Medicine to include re-education. The chart audits will continue for 3 months. At that time, the need for further chart reviews will be assessed.

5. Audit results will be forwarded to the Chair Department of Emergency and Hospital Medicine. In addition, the results will be reported to the Network Quality & Patient Safety Council and the CNO Council on a monthly basis, beginning in May 2020.

6. The Regional Chief Medical Officer is responsible for the implementation of and ongoing compliance with this plan of correction.
7. Patient Safety Officer reviewed The Medical Care Availability and Reduction of Error Act and Patient Safety Plan on March 13, 2020.
8. All patient safety events are reviewed by Patient Safety Officer to determine if the event meets the definition of a serious event. If the event meets the definition of a serious event per the Medical Care Availability and Reduction of Error Act they will be reported to the department and authority within 24 hours of facility's confirmation of the occurrence of the serious event and the facility will provide written notification to the patient.
9. The surgeon will inform the patient of the complication of surgery, and the Patient Safety Officer will send a letter of notification to the patient.


103.22 (b)(8) LICENSURE IMPLEMENTATION:State only Deficiency.
(8) The patient has the right to full information in laymen's terms, concerning his diagnosis, treatment, and prognosis, including information about alternative treatments and possible complications. When it is not medically advisable to give such information to the patient, the information shall be given on his behalf to the patient's next of kin or other appropriate person.
Observations:
Based on review of facility documents, medical records (MR) reviews and staff (EMP) interviews, it was determined the facility failed to ensure documentation of the verbal consent for treatment obtained via telephone included the name of the person giving the consent, their relationship to the patient, and the reason the written consent could not be obtained for two of 12 medical records reviewed (MR1 and MR5).

Findings include:

Review on February 21, 2020, of facility "Consent For Treatment - General," last reviewed August 26, 2019, revealed "...II. Policy: Policy Statement: Upon arrival to the hospital, the patient will be asked to sign a consent form for general treatment before such treatment can be initiated. Everyone eighteen (18) years of age or older, being of sound mind, had the right to decide whether to consent to medical diagnosis and treatment. III. Definitions: Incompetent - a condition in which an individual despite being provided appropriate medical information, communication supports, and technical assistance, is documented by a health care provider to be unable to understand the potential material benefits, risks, and alternatives involved in a specific proposed health care decision; unable to make that health care decision on his own behalf; or unable to communicate that health care decision to any other person. IV. Procedure: Guidelines: ... 6. In unusual circumstances when consent cannot be obtained in writing, in a timely manner, consent may be obtained by telephone. The telephone conversation shall be witnessed by an individual other than the individual obtaining the consent. The witness to the consent shall be identified to the person giving consent. The person giving consent shall be identified by name and relationship to the patient in the patient's medical record along with the reason why written consent could not be obtained and the nature of the consent obtained ..."

Review on February 19, 2020, of MR1 revealed the patient was nonverbal and accompanied to the ED by a caregiver from the patient's group home. The Consent for Treatment revealed documentation of verbal consent by telephone. There was no documentation of the name of the person giving the verbal consent, their relationship to the patient and the reason written consent could not be obtained.

Interview with EMP1 on February 20, 2020, at 2:40 PM, confirmed the Consent for Treatment for MR1 was a verbal consent received by telephone; there was no documentation of the name of the person giving the verbal consent, their relationship to the patient and the reason written consent could not be obtained.

Review on February 19, 2020, of MR5 revealed the patient was nonverbal. The Consent for Treatment revealed documentation of verbal consent by telephone. There was no documentation of the name of the person giving the verbal consent, their relationship to the patient and the reason written consent could not be obtained.

Interview with EMP1 on February 20, 2020, at 2:40 PM, confirmed the Consent for Treatment for MR5 was a verbal consent received by telephone; there was no documentation of the name of the person giving the verbal consent, their relationship to the patient and the reason written consent could not be obtained.





 Plan of Correction - To be completed: 04/05/2020

1. Registration staff will be educated by the Director of Registration and/or Supervisor of Registration on policy 'Consent to Treat, General' by March 20, 2020. The education includes the verbal consent process, which requires documentation in the medical record of the following for any verbal consent received by telephone: documentation of the name of the person giving the verbal consent, the individual's relationship to the patient and the reason a written consent could not be obtained.
2. Beginning March 23, 2020, a weekly audit of twenty medical records for emergency department patients will be reviewed by Director of Registration/Designee to ensure that any verbal consent received by telephone contains the three documentation requirements as stated in policy. Any area of non-compliance will be addressed by the Director of Registration/Registration Supervisor with the staff member to include re-education. The chart audits will continue for 3 months. At that time, the need for further chart reviews will be assessed.
3. Audit results will be forwarded to the Quality Department. In addition, the results will be reported to the Network Quality & Patient Safety Council and CNO Council on a monthly basis, beginning in April 2020 and the Professional Care Committee quarterly beginning May 2020.
4. The Director of Registration is responsible for the implementation of and ongoing compliance with this plan of correction.

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 review of facility documents, medical records (MR) and staff interview (EMP), it was determined the medical staff failed to adopt a policy that defined the expectations for evaluation and treatment of patients presenting to the Emergency Department (ED) with head injuries resulting in inconsistent treatment to patients with head injuries for 12 of 12 pertinent medical records reviewed (MR1 through MR12).

Findings include:

A review on February 20, 2020, of the "Amended and Restated Bylaws Schuylkill Medical Center-South Jackson Street," last reviewed November 2019, revealed "... Article VIII. Medical Staff Section 1. Medical Staff. The Board shall appoint an organized medical staff (the "Medical Staff") for the Hospital which shall operate in accordance with Medical Staff Bylaws ("Staff Bylaws") which shall be approved by the Board and by the Sole Member. The Medical Staff shall operate as an integral part of the Hospital and through its committees and Officers, shall be responsible for and accountable to the Board for the quality of medical care provided to patients of the Hospital ..."

Review of the "Medical Staff Rules and Regulations," last reviewed November 18, 2019, revealed "Introduction a. These Medical Staff Rules and Regulations are parameters for the conduct of professional clinical activities at the Hospital ... F. Emergency Department ... 3. Every patient presenting to the Emergency Department for care must be examined by a credentialed member of the Medical Staff, the Resident Staff, or the Allied Health Professional Staff ... 13. Diagnostic test will be done in the Emergency Department when necessary for timely diagnosis and treatment ... H. Records ... 2. (d.) Emergency Department Records ... For an emergency patient, documentation of patient's evaluation, diagnosis and treatment along with discharge instructions, will be the responsibility of the Medical Staff Member caring for the patient ..."

Review on February 19, 2020, of MR1 revealed this 59-year-old patient was seen in the ED on January 7, 2020, for injuries sustained in a fall downstairs. The patient sustained a laceration to the right outer ear and an abrasion to the right parietal scalp area. The patient was nonverbal and accompanied to the ED by a caregiver from the patient's group home. No computerized tomography (CT) scans or x-rays were completed. The laceration was cleansed, and then closed. The patient was discharged at 0729 on January 7, 2020. Discharge instructions for wound care were given. No instructions on monitoring for head injury symptoms were given on discharge.

Review of MR1's medical record from an outside hospital revealed, this patient required examination in another Emergency Department at 1224 on January 8, 2020. The patient had symptoms of stumbling, not moving head as normal and signs of pain. CT scans of the head and cervical spine were completed, and the patient was diagnosed with a subdural hematoma and a fracture of the cervical spine. The patient required transfer to a trauma center on January 8, 2020, for further treatment.

Review on February 19, 2020, of MR2 revealed this 76-year-old patient was seen in the ED on January 6, 2020, for an injury to the head, after a fall. This patient was verbal and complained of back pain and dizziness. No open skin areas were noted. CT scans of the head and lumbar spine were completed. Discharge instructions were given for fall prevention. No instruction to observe for neurological changes were given.

Review on February 19, 2020, of MR3 revealed this 79-year-old patient was seen in the ED on January 6, 2020, for a contusion and abrasion to the head, after a fall. This patient was verbal and offered no complaint of pain. CT scan of head was completed. Discharge instructions were given for care of a contusion. No instruction to observe for neurological changes were given.

Review on February 19, 2020, of MR4 revealed this 4-year-old patient was seen in the ED on January 6, 2020, with a head laceration, after a fall. The patient was verbal. No imaging studies were completed. Discharge instructions for care of the laceration were given. No instruction to observe for neurological changes were given.

Review on February 19, 2020, of MR5 revealed this 73-year-old patient was seen in the ED on January 7, 2020, with a scalp abrasion, after a fall out of bed. This patient was non-verbal. No caregiver from the patient's group home accompanied this patient. CT scans of head and cervical spine were completed. Discharge instructions were given for care of abrasion. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR6 revealed this 41-year-old patient was seen in the ED on January 7, 2020, for a laceration of the head. Patient hit self on the head with a guitar. This patient was alert and verbal. The laceration was closed after application of a local anesthetic. No CT scan or x-rays were completed. Patient left the ED without their discharge instructions.

Review on February 20, 2020, of MR7 revealed this 48-year-old patient was seen in the ED on January 20, 2020, for a contusion to the head following a fall and hitting head and back on concrete. This patient was verbal. Pain medication was given to this patient. CT of the spine and head were completed. Discharge instructions were for care of a contusion. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR8 revealed this 80-year-old patient was seen in the ED on January 20, 2020, for an eyebrow laceration sustained in a fall. This patient was verbal and reported no loss of consciousness. The laceration was repaired. CT of the spine and head were completed. Discharge instructions for care of the laceration were given. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR9 revealed this 20-year-old patient was seen in the ED on January 21, 2020, for a laceration to the head. This patient was non-verbal. Family was unsure if patient sustained the injury in a fall. The laceration was closed with staples after being cleansed. An attempt to apply an anesthetic to the area was made. A progress note indicated the patient was autistic and very difficult to hold still. Five staff members and a family member physically held the patient while the laceration was being stapled. Discharge instructions for care of the laceration were given. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR10 revealed this 3-year-old patient was seen in the ED on January 21, 2020, for a laceration of the ear following a fall from a bed. Family reported patient hit their head on a dresser. The ear laceration was closed with sutures after application of a local anesthetic. No CT scan or x-rays studies were completed. Discharge instructions for care of the laceration were given. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR11 revealed this 41-year-old patient was seen in the ED on January 20, 2020, for a minor head injury from a fall. The patient was nonverbal and accompanied to the ED by a caregiver from the patient's group home. No CT scan or x-rays were completed. Discharge instructions included monitoring for neurological changes.

Review on February 20, 2020, of MR12 revealed this 96-year-old patient was seen in the ED on January 8, 2020, for a head contusion following a fall. This patient was verbal. CT of the cervical and lumbar spine were completed. Discharge instructions were for care of a contusion. No instruction to observe for neurological changes were given.

Interview with EMP5 on February 19, 2020, at 3:15 PM, confirmed MR1 through MR5 were seen in the ED for a type of head injury. EMP5 confirmed MR2, MR3 and MR5 had CT scans of their head or spine and MR1 and MR4 did not have a CT scan of the head.
EMP5 confirmed MR4 received discharge instructions for monitoring a child with a head injury for the next 24 hours. EMP5 confirmed MR1, MR2, MR3 and MR5 did not receive instructions to monitor for neurological changes.

Interview with EMP5, at 10:40 AM, on February 20, 2010, confirmed MR6 through MR12 were seen in the ED for a type of head injury. EMP5 confirmed MR7, MR8 and MR12 had CT scans of their head and or spine and MR6, MR9, MR10 and MR11 did not have a CT scan of the head. EMP5 confirmed patients with head injuries received varying types of evaluation and treatment. EMP5 confirmed the facility does not have a policy or protocol to follow for treatment of patients with head injuries.

Interview with CF2, at 9:00 AM, on February 21, 2020, confirmed ED patients may receive varying treatments for their head injuries and the ED does not have a policy or protocol to follow for evaluation, treatment and discharge instruction of patients with head injuries. CF2 stated they were going to develop a head injury protocol.




 Plan of Correction - To be completed: 04/05/2020

1. A clinical protocol for pediatric head injury, last updated 3/15/19, provides an algorithm for providers on consistent evaluation and documentation of care for pediatric patients presenting to the Emergency Department within 24 hours of head injury. Additionally, the algorithm standardizes provision of discharge education and is cognizant of unnecessary radiation exposure. An Emergency Department algorithm for adult head injury will be developed by the Vice Chair Department of Emergency and Hospital Medicine by March 23, 2020. The algorithm will guide the emergency department providers on the consistent evaluation and documentation of care, including provision of appropriate discharge instructions, for adult patients presenting to the Emergency Department with head injuries. The practice of the Emergency Department has been to perform CT imaging on patients over the age of 70 that present with head injury, which was confirmed during survey chart review and stated in deficiency report.

2. Physicians and Advanced Practice Professionals in the Emergency Department will receive education on the new algorithm for adult head injury, inclusive of the use and documentation of appropriate discharge instructions for patients with head injury by March 31, 2020 by the Vice Chair Department of Emergency and Hospital Medicine.

3. Beginning April 5, 2020 a weekly audit of ten medical records for all patients that present to the emergency department for a diagnosis of a head injury will be completed by Quality Department/Designee to ensure that all patients receiving treatment for a head injury were evaluated and received care based on the algorithm and were provided appropriate discharge instructions for head injury. Any non-compliance will be addressed by the Regional Chief Medical Officer and/or Vice Chair Department of Emergency and Hospital Medicine to include re-education. The chart audits will continue for 3 months. At that time, the need for further chart reviews will be assessed.

4. Audit results will be forwarded to the Chair Department of Emergency Medicine and Hospital Medicine and Regional Chief Medical Officer. In addition, the results will be reported to the Network Quality & Patient Safety Council on a monthly basis, beginning in May 2020 and the Professional Care Committee quarterly beginning May 2020.

5. The Regional Chief Medical Officer is responsible for the implementation of and ongoing compliance with this plan of correction.



117.41 (b)(19) LICENSURE EMERGENCY PATIENT CARE:State only Deficiency.
117.41 Emergency patient care
(b) Policies and procedures for
emergency patient care should, at a
minimum, do the following:
(19) Delineate instructions to be
given to a patient or the patient's
family, or both, or others as appropriate
regarding follow-up care.
Observations:

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the medical staff failed to adopt a policy that defined the expectations for discharge instructions to patients presenting to the Emergency Department (ED) with head injuries resulting in inconsistent discharge instructions being given to patients with head injuries for 12 of 12 pertinent medical records reviewed (MR1 through MR12).

Findings include:

Review of the "Medical Staff Rules and Regulations," last reviewed November 18, 2019, revealed "Introduction a. These Medical Staff Rules and Regulations are parameters for the conduct of professional clinical activities at the Hospital ... F. Emergency Department ... 3. Every patient presenting to the Emergency Department for care must be examined by a credentialed member of the Medical Staff, the Resident Staff, or the Allied Health Professional Staff ... 13. Diagnostic test will be done in the Emergency Department when necessary for timely diagnosis and treatment ... H. Records ... 2. (d.) Emergency Department Records ... For an emergency patient, documentation of patient's evaluation, diagnosis and treatment along with discharge instructions, will be the responsibility of the Medical Staff Member caring for the patient ..."

Review on February 21, 2020, of facility "Discharge of Patients From the Emergency Department - Emergency Medicine," last reviewed October 9, 2019, revealed "... II. Policy: To assure a consistent process of discharge of emergency department patients. All patients discharged from the emergency department will have an appropriate follow-up plan of care discussed with them prior to discharge. ... IV. Procedure: ... 3. Discuss discharge instructions and plan with patient and/or appropriate responsible parties. ... 7. Give copy of discharge instructions and al prescriptions as indicated to the patient/family ..."

Review on February 19, 2020, of MR1 revealed this 59-year-old patient was seen in the ED on January 7, 2020, for injuries sustained in a fall downstairs. The patient sustained a laceration to the right outer ear and an abrasion to the right parietal scalp area. The patient was nonverbal and accompanied to the ED by a caregiver from the patient's group home. No computerized tomography (CT) scans or x-rays were completed. The laceration was cleansed and then laceration closed. The patient was discharged at 0729 on January 7, 2020. Discharge instructions for wound care were given. No instructions on monitoring for head injury symptoms were given on discharge.

Review of MR1's medical record from an outside hospital revealed, this patient required examination in another Emergency Department at 1224 on January 8, 2020. The patient had symptoms of stumbling, not moving head as normal and signs of pain. CT scans of the head and cervical spine were completed, and the patient was diagnosed with a subdural hematoma and a fracture of the cervical spine. The patient required transfer to a trauma center on January 8, 2020, for further treatment.

Review on February 19, 2020, of MR2 revealed this 76-year-old patient was seen in the ED on January 6, 2020, for an injury to the head, after a fall. This patient was verbal and complained of back pain and dizziness. No open skin areas were noted. CT scans of the head and lumbar spine were completed. Discharge instructions were given for fall prevention. No instruction to observe for neurological changes were given.

Review on February 19, 2020, of MR3 revealed this 79-year-old patient was seen in the ED on January 6, 2020, for a contusion and abrasion to the head, after a fall. This patient was verbal and offered no complaint of pain. CT scan of head was completed. Discharge instructions were given for care of a contusion. No instruction to observe for neurological changes were given.

Review on February 19, 2020, of MR4 revealed this 4-year-old patient was seen in the ED on January 6, 2020, with a head laceration, after a fall. The patient was verbal. No imaging studies were completed. Discharge instructions for care of a child with a minor head injury were given [won't stop crying, becomes very sleepy, complains of dizziness, becomes restless or confused, complains of head or neck pain or stiffness or vomits].

Review on February 19, 2020, of MR5 revealed this 73-year-old patient was seen in the ED on January 7, 2020, with a scalp abrasion, after a fall out of bed. This patient was non-verbal. No caregiver from the patient's group home accompanied this patient. CT scans of head and cervical spine were completed. Discharge instructions were given for care of abrasion. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR6 revealed this 41-year-old patient was seen in the ED on January 7, 2020, for a laceration of the head. Patient hit self on the head with a guitar. This patient was alert and verbal. The laceration was closed after application of a local anesthetic. No CT scan or x-rays were completed. Patient left the ED without their discharge instructions.

Review on February 20, 2020, of MR7 revealed this 48-year-old patient was seen in the ED on January 20, 2020, for a contusion to the head following a fall and hitting head and back on concrete. This patient was verbal. Pain medication was given to this patient. CT of the spine and head were completed. Discharge instructions were for care of a contusion. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR8 revealed this 80-year-old patient was seen in the ED on January 20, 2020, for an eyebrow laceration sustained in a fall. This patient was verbal and reported no loss of consciousness. The laceration was repaired. CT of the spine and head were completed. Discharge instructions for care of the laceration were given. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR9 revealed this 20-year-old patient was seen in the ED on January 21, 2020, for a laceration to the head. This patient was non-verbal. Family was unsure if patient sustained the injury in a fall. The laceration was closed with staples after being cleansed. An attempt to apply an anesthetic to the area was made. A progress note indicated the patient was autistic and very difficult to hold still. Five staff members and a family member physically held the patient while the laceration was being stapled. Discharge instructions for care of the laceration were given. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR10 revealed this 3-year-old patient was seen in the ED on January 21, 2020, for a laceration of the ear following a fall from a bed. Family reported patient hit their head on a dresser. The ear laceration was closed with sutures after application of a local anesthetic. No CT scan or x-rays studies were completed. Discharge instructions for care of the laceration were given. No instruction to observe for neurological changes were given.

Review on February 20, 2020, of MR11 revealed this 41-year-old patient was seen in the ED on January 20, 2020, for a minor head injury from a fall. This patient was non-verbal and was accompanied to the ED by a caregiver from the patient's group home. No CT scan or x-rays were completed. Discharge instructions included monitoring for neurological changes.

Review on February 20, 2020, of MR12 revealed this 96-year-old patient was seen in the ED on January 8, 2020, for a head contusion following a fall. This patient was verbal. CT of the cervical and lumbar spine were completed. Discharge instructions were for care of a contusion. No instruction to observe for neurological changes were given.

Interview with EMP5 on February 19, 2020, at 3:15 PM, confirmed MR1 through MR5 were seen in the ED for a type of head injury. EMP5 confirmed MR2, MR3 and MR5 had CT scans of their head or spine and MR1 and MR4 did not have a CT scan of the head.
EMP5 confirmed MR4 received discharge instructions of what a child should be watched for over the next 24 hours. EMP5 confirmed MR1, MR2, MR3 and MR5 did not receive instructions to monitor for neurological changes.

Interview with EMP5 on February 19, 2020, at 3:15 PM, confirmed MR1 through MR5 were seen in the ED for a type of head injury. EMP5 confirmed MR2, MR3 and MR5 had CT scans of their head or spine and MR1 and MR4 did not have a CT scan of the head.
EMP5 confirmed MR4 received discharge instructions for monitoring a child with a head injury for the next 24 hours. EMP5 confirmed MR1, MR2, MR3 and MR5 did not receive instructions to monitor for neurological changes.

Interview with EMP5, at 1040, on February 20, 2010, confirmed MR6 through MR12 were seen in the ED for a type of head injury. EMP5 confirmed MR7, MR8 and MR12 had CT scans of their head and or spine and MR6, MR9, MR10 and MR11 did not have a CT scan of the head. EMP5 confirmed MR11 received discharge instructions to monitor the patient for neurological changes. EMP5 confirmed MR7, MR8, MR9, MR10 and MR12 did not receive instructions to monitor for neurological changes. EMP5 confirmed patients with head injuries received varying types of evaluation, treatment and discharge instruction. EMP5 confirmed the facility does not have a policy or protocol to follow for treatment of patients with head injuries.

Interview with CF2, at 0900, on February 21, 2020, confirmed ED patients may receive varying treatments for their head injuries and the ED does not have a policy or protocol to follow for evaluation, treatment and discharge instruction of patients with head injuries. CF2 stated they were going to develop a head injury protocol.

Interview with EMP1 on February 21, 2020, at approximately 1:35 PM, confirmed MR1's discharge instructions did not include observation for neurological changes. EMP1 confirmed the electronic medical record system chooses the discharge instructions according to the diagnosis. If the diagnosis was listed as a laceration or a contusion, and not head injury, only the laceration or contusion discharge instruction would be generated and given to the patient.





 Plan of Correction - To be completed: 04/05/2020

1. A clinical protocol for pediatric head injury, last updated 3/15/19, provides an algorithm for providers on consistent evaluation and documentation of care for pediatric patients presenting to the Emergency Department within 24 hours of head injury. Additionally, the algorithm standardizes provision of discharge education and is cognizant of unnecessary radiation exposure. An Emergency Department algorithm for adult head injury will be developed by the Vice Chair Department of Emergency and Hospital Medicine by March 23, 2020. The algorithm will guide the emergency department providers on the consistent evaluation and documentation of care, including provision of appropriate discharge instructions, for adult patients presenting to the Emergency Department with head injuries. The practice of the Emergency Department has been to perform CT imaging on patients over the age of 70 that present with head injury, which was confirmed during survey chart review and stated in deficiency report.

2. Physicians and Advanced Practice Professionals in the Emergency Department will receive education on the new algorithm for adult head injury, inclusive of the use and documentation of appropriate discharge instructions for patients with head injury by March 31, 2020 by the Vice Chair Department of Emergency and Hospital Medicine.

3. Beginning April 5, 2020 a weekly audit of ten medical records for all patients that present to the emergency department for a diagnosis of a head injury will be completed by Quality Department/Designee to ensure that all patients receiving treatment for a head injury were evaluated and received care based on the algorithm and were provided appropriate discharge instructions for head injury. Any non-compliance will be addressed by the Regional Chief Medical Officer and/or Vice Chair Department of Emergency and Hospital Medicine to include re-education. The chart audits will continue for 3 months. At that time, the need for further chart reviews will be assessed.

4. Audit results will be forwarded to the Chair Department of Emergency Medicine and Hospital Medicine and Regional Chief Medical Officer. In addition, the results will be reported to the Network Quality & Patient Safety Council on a monthly basis, beginning in May 2020 and the Professional Care Committee quarterly beginning May 2020.

5. The Regional Chief Medical Officer is responsible for the implementation of and ongoing compliance with this plan of correction.




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