Observations:
Based on review of facility documents, medical records (MR) and staff interviews (EMP) it was determined the facility failed to ensure that good management techniques were implemented to avoid the personal discomfort of a patient for one of one medical record reviewed (MR1).
Findings include:
Review of facility policy "Patient's Rights and Responsibilities" last reviewed June 2023, revealed "Scope and Purpose - To communicate the expectations of hospital personnel regarding patient rights and patient responsibilities. ... Addendum A: A Statement of the Patient's Rights As a healthcare facility, we are committed to delivering quality medical care to you, our patient, and to making your stay as pleasant as possible. The following "Statement of Patient's Rights" was developed by the Department of Health. The administration and staff of SJRHN endorse these rights. It is our goal to provide effective, considerate medical care within our capacity, mission, philosophy, applicable law and regulation. We submit these to you as a statement of our policy. ... You have the right to expect good management techniques to be implemented within the hospital, the avoidance of unnecessary delays and, when possible, the avoidance of personal discomfort through effective pain management."
Review of MR1 on August 16, 2024, revealed on May 14, 2024, MR1 had a biopsy completed at 1045 and returned to the hospital at 1300 for complaints of complications with pain and swelling due to biopsy. MR1 was sent back home. Around 1700, EMP2 called in a Pre-Arrival summary for MR1 to be seen in the Emergency Department (ED) due to complications that required skills of other practitioners. During ED visit MR1 was noted to have ecchymosis to the right breast and had a Computed Tomography (CT) scan that reported MR1 had a 7.1 x 7.4 cm mass with edema. Note entered by EMP3 at 2248 that a call was made to EMP4 (surgeon) for MR1 complications that required specific skills of other Practitioners. EMP3 discharged MR1 from the ED to home on May 14, 2024, at 2316. On May 15, 2024, EMP5 had MRI return to the facility and directly admitted MR1 to have surgical evacuation of large right breast hematoma.
Further review of MR1 revealed that on May 14, 2024, there is no consult request order entered by EMP3, and there is no consultation report documented by EMP4 per policy.
Interview with EMP3 on August 16, 2024, confirmed a call was made to EMP4 on May 14, 2024, due to MR1 complications requiring specific skills of surgeon. EMP3 also confirmed MR1 was discharged home for a second time for the same complication.
Interview with EMP4 on August 16, 2024, confirmed a call was received from EMP3 on May 14, 2024, about MR1 complications and EMP4 also confirmed that EMP4 did not review MR1, document or make notes in MRI.
Interview on August 16, 2024, with EMP5 confirmed EMP5 was notified by EMP2 that MR1 was being sent to the ED on May 14, 2024, for complications that required being assessed by practitioners of the surgery team. EMP5 also confirmed MR1 was directly admitted on May 15, 2024, for surgical procedure due to the complications that occurred on May 14, 2024 from the biopsy.
Interview with EMP1 on August 16, 2024, EMP1 confirmed all information above was complete and accurate.
| | Plan of Correction - To be completed: 10/30/2024
Penn State Health St. Joseph (PSHSJ) had an unannounced onsite complaint visit on August 23, 2024. The visit, staff interviews and subsequent chart review identified an area of noncompliance 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 187, as amended June 1998. PSHSJ has developed a comprehensive plan for improving the processes that led to the deficiency cited, including how the hospital is addressing improvements in its systems to prevent the likelihood of recurrence of the deficient practice.
The team identified to review the deficiency, design the Plan of Correction (PoC), and implement the PoC included the Vice President of Medical Affairs/Patient Safety Officer as the facilitator, Vice President, Chief Nursing Officer, Director of Critical Care/Emergency Services/House Supervisor/Dialysis, Emergency Department Nurse Manager, Medical Director/Department Chair Emergency Medicine and Medical Director Surgical Services/Department Chair Surgery.
The team decided that the first step in the PoC is to ensure that all surgical consult orders be placed in the electronic medical record in addition to any verbal communication between the Emergency Department (ED) provider and surgeon. All surgical consultations will be completed according to the timeframes specified in the PSHSJ Rules and Regulations and will be documented in the electronic medical record. Education on this topic will be provided to the ED providers at the next Emergency Department Provider meeting on 9/18/24. A signed attestation from all ED providers will be returned to the Vice President Medical Affairs/Patient Safety Officer by 10/18/24, verifying their receipt of this information.
The Patient Rights and Responsibilities policy will be updated, reviewed and approved on an annual basis.
This policy will be uploaded into PSHSJ Compass Educational System. All employees will be expected to read the policy and execute a required attestation within 60 days of submission of this Corrective Action Plan. Going forward, the review of these policies and the execution of the attestation will be required on an annual basis.
The leadership responsible for overall oversight of the implementation of the PoC includes, Vice President of Medical Affairs/Patient Safety Officer and Vice President, Chief Nursing Officer.
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