Initial Comments:
This report is the result of an unannounced complaint investigation CHL24C205H completed on March 25, 2024, at Lancaster General 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:
103.34 LICENSURE
PERSONNEL POLICIES AND PRACTICES
Name - Component - 00
103.34 Personnel policies and
practices
The governing body, through the
chief executive officer, shall ensure
that personnel policies and practices
which adequately support sound patient
care are established and maintained.
The policies shall be reduced to
writing and made available to all
employes, and they shall be reviewed
periodically, but no less often than
two years. The date of the most recent
review shall be indicated on the
written policies. A procedure shall be
established for notifying employes of
changes in the established personnel
polices.
Observations:
Based on review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to follow their approved stroke management protocol in order to provide sound patient care in one of one MR reviewed (MR1).
Findings include:
On March 20, 2024, review of facility policy "Ischemic Stroke Management Protocol" last revised October 12, 2022, revealed "Purpose: To outline the management of patients with a new or suspected diagnosis of stroke. POLICY STATEMENT(S) Lancaster General Hospital follows the AHA/ASA Guidelines for care and management of the patient with a known or suspected stroke. Caring for ischemic and hemorrhagic stroke patients is described in this Policy as well as the Hemorrhagic Stroke Management Policy. The Stroke Alert Process Flow applies to both stroke populations. A. Patients Eligible for Mechanical Thrombectomy 1. Patients with Large Vessel Occlusion up to 6 hours 2. Patients with Large Vessel Occlusion from 6 to 24 hours with appropriate tissue signal (CTP result). ... A. Assessment and Care of all other Stroke patients a. Swallow screening test by ED nurse prior to oral aspirin (must meet criteria to receive oral aspirin or other oral intake I. Administer ASA rectally if swallow screen not passed (nonthrombolytic) b. NIHSS score on admission, post-intervention, transfer, daily and any time change in neurological status is observed c. Continuous cardiac monitoring for at least the first 24 to 48 hours of admission d. Follow brain imaging to asses for hemorrhage e. Measure intake and output f. Bed rest- HOB elevated 30 degrees; maintain good head and body alignment to prevents increased intrathoracic pressure and allow venous drainage ... i. Frequent assessment for early ambulation when vital signs are stable ii. Encourage OOB TID g. Assess and manage pain h. keep patient NPO, including no oral medications, until swallowing assessed."
On March 18, 2024, review of MR1 revealed, Patient arrived at the Emergency Department (ED) on January 20, 2023, at 11:56 AM and was seen in triage at 12:16 PM. Provider EMP4, noted patient came in for left-sided weakness which was observed upon assessment, differential diagnoses included intracranial mass, stroke, other. After triage screening plan was noted to obtain labs and imaging studies. Patient remained in ED waiting room until 8:23 PM and was admitted to hospital from the ED at 11:23 PM. An order was placed at 9:09 PM for an aspirin chewable tablet, 324 mg, and administered by EMP 5 at 9:12 PM. At 9:38 PM an order was entered to elevate the head of bed (HOB) 30 degrees.
There is no documentation noted in MR1 of a swallow screen being performed prior to chewable aspirin being administered and no documentation noted of patient's HOB being elevated during admission stay per facility policy.
Interview with EMP2 on March 20, 2024, EMP2 confirmed a swallow screen was not performed prior to patient being administered chewable aspirin per policy.
Interview with EMP3 on March 20, 2024, EMP3 confirmed there is no documentation that the patient's HOB was elevated to 30 degrees per order and policy.
Interview with EMP1 on March 20, 2024, EMP1 confirmed all information submitted is complete and accurate.
Plan of Correction:Action: Executive responsible for oversight of Plan of Correction to ensure the safety of stroke patients.
Responsible Party: Chief Nursing Officer
Completion Date: March 25, 2024
Action: Educate ED RNs to complete and document swallow evaluation prior to medication administration for stroke alert patients and patients with stroke symptoms outside of the treatment window.
Responsible Party: Nurse Manager, ED
Completion Date: April 30, 2024
Action: Educate 7 Lime RNs to follow physician orders for head of bed elevation and document appropriately in patient chart.
Responsible Party: Nurse Manager, 7 Lime
Completion Date: April 30, 2024
Action: Audit documentation of swallow evaluation on 50 stroke patients per month arriving in the ED for 60 days with an anticipated compliance rate of 95%.
Responsible Party: Nurse Manager, ED
Completion Date: June 30, 2024
|