Pennsylvania Department of Health
SAINT VINCENT SURGERY CENTER OF ERIE
Patient Care Inspection Results

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SAINT VINCENT SURGERY CENTER OF ERIE
Inspection Results For:

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SAINT VINCENT SURGERY CENTER OF ERIE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

This report is the result of a full State Licensure survey conducted on April 13, 2023, with review of additional information concluding on June 2, 2023, at Saint Vincent Surgery Center of Erie. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Ambulatory Care Facilities, Annex A, Title 28, Part IV, Subparts A and F, Chapters 551-573, November 1999.




 Plan of Correction:


553.3 (1) LICENSURE Governing Body Responsibilities:State only Deficiency.
553.3
Governing Body responsibilities include:

(1) Conforming to all applicable Federal, State, and local laws.

Observations:

Based on review of facility documentation and employee interviews (EMP), it was determined that the facility failed to conform to all applicable State Laws.

Saint Vincent Surgery Center of Erie was not in compliance with the following State Law:

The Medical Care Availability and Reduction of Error Act 13 of 2002, Chapter 3, Section 313. "Medical Facility Reports and Notifications. ... (c) Infrastructure failure reports - A medical facility shall report the occurrence of an infrastructure to the department within 24 hours of the medical facility's confirmation of the occurrence or discovery of the infrastructure failure."
This regulation was not met as evidenced by:
Based on review of facility documentation and employee interview (EMP), it was determined that the facility failed to report three identified infrastructure failures within 24 hours of confirmation of the occurrence or discovery of the infrastructure.
Findings include:
Review on May 25, 2023, at approximately 9:00 AM of Policy 5955029, "Incident Reporting for Patients and Visitors," revised September 27, 2022, revealed, "... Terms and Definitions ... E. Infrastructure Failure - An undesirable or unintended event, incident or situation involving the infrastructure of a medical facility or the discontinuation of significant disruption of service which could seriously compromise patient safety. ..."
1. Review on May 25, 2023, at approximately 9:30 AM of an event report, dated March 31, 2022, revealed that a procedure was paused when EMP2 responded to an on-call event outside of the facility on March 28, 2022.
EMP3 confirmed the paused procedure was not submitted as an infrastructure failure on June 2, 2023.
2. Review on May 25, 2023, at approximately 11:00 AM of the facility's incident log revealed that two procedures were cancelled on September 9, 2023, when EMP1 responded to an emergency on-call request at another facility.
EMP3 confirmed that the identified events were not submitted as infrastructure failures on May 25, 2023.

Cross reference:
Implementation






 Plan of Correction - To be completed: 05/01/2023

Saint Vincent surgery Center Director of Nursing will be responsible to ensure all appropriate actions are taken.

1. Saint Vincent Surgery Center Director of Nursing and Quality RN will review infrastructure failure reporting guidelines completed 4/24/23.
2. Saint Vincent Surgery Center Director of Nursing or designee will review all event reports and monitor compliance with Infrastructure failure reporting.
3. Saint Vincent Surgery Center Director of Nursing or designee will continue to present event reports and findings to SVSC Patient Safety Committee and SVH Patient Safety Committee Quarterly.
4. The Saint Vincent Surgery Center Director of Nursing will continue to review the meeting minutes quarterly for accuracy and maintain meeting minutes on site at SVSC.

553.12 (b)(15) LICENSURE Implementation:State only Deficiency.
553.12
(b) The following are the minimal provisions for the patient's bill of
rights:
(15) The patient has the right to expect good management techniques to
be implemented within the ASF. These techniques shall make effective use of
the time of the patient and avoid the personal discomfort of the patient.

Observations:

Based on review of facility documentation it was determined that the facility failed to ensure the effective use of the time of the patient and avoid personnel discomfort of the patient when EMP1 and EMP2 left the facility during scheduled procedure times.

Findings include:

Review on May 23, 2023, at approximately 2:50 PM of Policy 4495102, "On-Call Coverage by Medical Staff Members for Unassigned or Staff Service Patient, C732," approved December 3, 2021, revealed, "... 3. If a member of the medical staff who is required to accept emergency service calls for patients is unable to accept emergency service, it is his/her responsibility to make other arrangements in advance for his/her assigned call to insure that the AHN on call calendar is updated. ..."

Review on May 29, 2023, at approximately 10:00 AM of the scheduled surgical procedures for March 28, 2022, revealed that a procedure was scheduled for 11:30 AM same day.

1. Review on May 25, 2023, at approximately 9:30 AM of an event submitted to the Department revealed that a procedure was paused when EMP2 responded to an emergency on-call request at another facility.

Review on May 29, 2023, at approximately 10:00 AM of the scheduled procedures for September 9, 2023, revealed two procedures were scheduled at 10:45 AM and 12:00 PM same day.

2. Review on May 25, 2023, at approximately 11:00 AM of the facility's incident log revealed two cases were cancelled on September 9, 2023, when EMP1 responded to an emergency on-call request at another facility.

cross reference:
Governing Body Responsibilities











 Plan of Correction - To be completed: 06/13/2023

The Chief Medical Officer is ultimately responsible for the below plan of correction.
1. Per the AHN Medical Staff Rules and Regulations and Staff By-Laws, Physicians are permitted to be on-call at locations while performing elective surgeries.
2. Physicians are to follow the AHN Physician On-Call policy for incidents of Emergencies and on-call requirements.
3. The On-Call Policy and Medical Staff Rules and Regulations was reviewed at the Medical Executive Committee Meeting on 6/13/2023.
4. An update was made to include the verbiage from the AHN Physician On-Call Policy to the Medical Staff Rules and Regulations.
5. The AHN Physician On-call policy outlines the steps to take if an emergency arises while on-call.
6. Updates and changes will be provided and communicated the Medical Staff.
7. Incidents will be reported into the Internal Reporting System and will be reported to the CMO.
8. All incidents will be reviewed and reported appropriately by the Director of Nursing in conjunction with the CMO.
9. Any incidents of noncompliance with the AHN On-Call Policy will be addressed through the enforcement section in the AHN on-call Policy through the Leadership committee.


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