QA Investigation Results

Pennsylvania Department of Health
CROZER-CHESTER MEDICAL CENTER
Health Inspection Results
CROZER-CHESTER MEDICAL CENTER
Health Inspection Results For:


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Initial Comments:

This report is the result of an unannounced onsite special monitoring visit (PA00061366) completed on December 28, 2022, at Crozer-Chester Medical Center. Based on the investigation it was determined that the facility was not in compliance with standard level findings and in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.







Plan of Correction:




482.13(c)(2) STANDARD
PATIENT RIGHTS: CARE IN SAFE SETTING

Name - Component - 00
The patient has the right to receive care in a safe setting.

Observations:

Based on review of facility policy, medical record (MR), and staff interviews (EMP), it was determined the facility failed to ensure one patient that was involuntarily committed was provided a safe environment.

Findings include:

Review of facility documents Patient Rights and Responsibilities, Effective 11/30/2020, "I. Policy Statement: Crozer Health (CH) is committed to notifying and educating our patients about their rights and responsibilities in order to deliver the highest quality of care in a transparent, collaborative setting. ... II. Patient Rights and Responsibilities ... Your Rights ... As our patient, you have the right ... Receive kind, respectful, safe quality care delivered by skilled staff ... "

Review of Involuntary Mental Health Commitments and Voluntary Mental Health Admissions, Effective Date: 06/28/2021, "I. Policy: It is the policy of Crozer Health Hospitals that all patients receive the appropriate evaluation and determination for ongoing treatment. In this evaluation process, the hospitals will maintain a reliable system for insuring patients' safety and rights, as defined by the Mental Health Procedures Act of 1976 ..."
MR11 review revealed "ED Note 12/14/2022 [gender] 20s to ED complaining of stab wounds ... schizophrenic, stab wounds self-inflicted ... 12/14/2022 Trauma HP Assessment/Plan: 21 yo [gender] with stab wounds ... Intubated and taken to CT scanner in stable condition - will go to the OR for diagnostic ... 12/14/2022 Operative report ... Patient tolerated all procedures well and transported to the shock trauma unit in stable condition ..."
Further review of the medical record revealed "12/15/2022 ED Note-Physician @ 702 we are paged by the trauma ICU nurse that the patient was exhibiting violent behavior standing up ... and attempting to stab people and [gender] self with a sharp object. ... the patient began to grab ... with a sharp object and appeared to stab [gender] self ... I was paged by the resident that patient had stabbed [gender] self with the scissors ... "
Interview with EMP1 on December 19, 2022, at approximately 2:00 PM revealed that a nurse was providing care to the patient and when cleaning up, the nurse left the scissors within patient reach.








Plan of Correction:

Members of the Crozer Chester Medical Center (CCMC) leadership team met on 1/19/2022 to review each citation, existing processes, and possible opportunities related to Patient Rights. Members of the team included the Chief Nurse Executive, Chief Nursing Officer, Director of Nursing Education, Chief Quality Officer, Patient Safety Officer, Clinical Directors, and the Regulatory Department. Based on this review, the team has developed the following plan of correction.

Education on Patient Rights will be provided to all Nursing Staff on the Surgical Trauma Unit. The education will be initiated by 1/27/2023. 100% of available staff will complete this education by 2/24/2023.

The Chief Quality Officer or designee will initiate audits of all patients who are involuntary commitments and are under constant observation. This audit will capture data relating to the proximity of the companion to the patient, whether or not the environmental checklist was completed, whether the safety observation checklist was completed, etc. This audit will be conducted five days per week on 100% of patients who are involuntarily committed and under constant observation. These audit results will be completed until 100% compliance has been achieved for three consecutive months. Audit results will be reported by the Chief Quality Officer or designee to the Quality-of-Care Committee monthly.



Initial Comments:
This report is the result of an unannounced onsite special monitoring investigation completed on December 28, 2022, at Crozer-Chester Medical Center. 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:




103.22 (b)(16) LICENSURE
IMPLEMENTATION

Name - Component - 00
103.22
(16) The patient has the right to expect good management techniques to be implemented within the hospital considering effective use of the time of the patient and to avoid the personal discomfort of the patient.

Observations:

Based on review of facility policy, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to implement good management techniques to avoid personal discomfort for patients in one of eleven medical records reviewed (MR11).

Findings include:

Review of facility documents Patient Rights and Responsibilities, Effective 11/30/2020, "I. Policy Statement: Crozer Health (CH) is committed to notifying and educating our patients about their rights and responsibilities in order to deliver the highest quality of care in a transparent, collaborative setting. ... II. Patient Rights and Responsibilities ... Your Rights ... As our patient, you have the right ... Receive kind, respectful, safe quality care delivered by skilled staff ... "

Review of Involuntary Mental Health Commitments and Voluntary Mental Health Admissions, Effective Date: 06/28/2021, "I. Policy: It is the policy of Crozer Health Hospitals that all patients receive the appropriate evaluation and determination for ongoing treatment. In this evaluation process, the hospitals will maintain a reliable system for insuring patients' safety and rights, as defined by the Mental Health Procedures Act of 1976 ..."
MR11 review revealed "ED Note 12/14/2022 [gender] 20s to ED complaining of stab wounds ... schizophrenic, stab wounds self-inflicted ... 12/14/2022 Trauma HP Assessment/Plan: 21 yo [gender] with stab wounds ... Intubated and taken to CT scanner in stable condition - will go to the OR for diagnostic ... 12/14/2022 Operative report ... Patient tolerated all procedures well and transported to the shock trauma unit in stable condition ..."
Further review of the medical record revealed "12/15/2022 ED Note-Physician @ 702 we are paged by the trauma ICU nurse that the patient was exhibiting violent behavior standing up ... and attempting to stab people and [gender] self with a sharp object. ... the patient began to grab ... with a sharp object and appeared to stab [gender] self ... I was paged by the resident that patient had stabbed [gender] self with the scissors ... "
Interview with EMP1 on December 19, 2022, at approximately 2:00 PM revealed that a nurse was providing care to the patient and when cleaning up, the nurse left the scissors within patient reach.







Plan of Correction:

Members of the Crozer Chester Medical Center (CCMC) leadership team met on 1/19/2022 to review each citation, existing processes, and possible opportunities related to Patient Rights. Members of the team included the Chief Nurse Executive, Chief Nursing Officer, Director of Nursing Education, Chief Quality Officer, Patient Safety Officer, Clinical Directors, and the Regulatory Department. Based on this review, the team has developed the following plan of correction.

Education on Patient Rights will be provided to all Nursing Staff on the Surgical Trauma Unit. The education will be initiated by 1/27/2023. 100% of available staff will complete this education by 2/24/2023.

The Chief Quality Officer or designee will initiate audits of all patients who are involuntary commitments and are under constant observation. This audit will capture data relating to the proximity of the companion to the patient, whether or not the environmental checklist was completed, whether the safety observation checklist was completed, etc. This audit will be conducted five days per week on 100% of patients who are involuntarily committed and under constant observation. These audit results will be completed until 100% compliance has been achieved for three consecutive months. Audit results will be reported by the Chief Quality Officer or designee to the Quality-of-Care Committee monthly.


109.21 LICENSURE
POLICIES - PRINCIPLE

Name - Component - 00
109.21 Principle

Written nursing care and administrative policies and procedures shall be developed to provide the nursing staff with methods of meeting its responsibilities and achieving goals.

Observations:

Based on review of facility policy, facility documents and interview with staff (EMP), it was determined the facility failed to comply with its adopted policy for Suicide Precautions for one of eleven medical records reviewed (MR11).
Findings include:
Review of Suicide Precautions policy, effective Date: 04/14/2022, revealed "Suicide Precautions are instituted for patients who pose a risk of physical harm to themselves. Purpose: To provide a safe environment for patients and staff. ... Procedure: 3. Environmental Safety Check ... ii. Environment checks are performed and documented by the Registered Nurse on the Safety Observation Checklist every eight hours to assure maintained safety ...."
Review of Safety Observation Checklist revealed, "Environmental Safety Check Performed" was not documented: December 15, 2022, 1500-2300; December 16, 2022, 0700-1500 and 1500-2300; December 17, 2022, 0700-1500; December 18, 2022, 0700-1500.
Interview with EMP1 on January 10, 2023, at approximately 1:30 PM confirmed there was no documentation on the Safety Observation Checklist to show that environmental safety checks were performed.






Plan of Correction:

Members of the Crozer Chester Medical Center (CCMC) leadership team met on 1/19/2022 to review each citation, existing processes, and possible opportunities related to Patient Rights. Members of the team included the Chief Nurse Executive, Chief Nursing Officer, Director of Nursing Education, Chief Quality Officer, Patient Safety Officer, Clinical Directors, and the Regulatory Department. Based on this review, the team has developed the following plan of correction.

Education on Patient Rights will be provided to all Nursing Staff on the Surgical Trauma Unit. The education will be initiated by 1/27/2023. 100% of available staff will complete this education by 2/24/2023.

The Chief Quality Officer or designee will initiate audits of all patients who are involuntary commitments and are under constant observation. This audit will capture data relating to the proximity of the companion to the patient, whether or not the environmental checklist was completed, whether the safety observation checklist was completed, etc. This audit will be conducted five days per week on 100% of patients who are involuntarily committed and under constant observation. These audit results will be completed until 100% compliance has been achieved for three consecutive months. Audit results will be reported by the Chief Quality Officer or designee to the Quality-of-Care Committee monthly.