Initial Comments:
This report is the result of an unannounced onsite complaint investigation, CHL24C241V, initiated on April 1, 2024 and completed offsite April 8, 2024, at Suburban Community 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:
103.4 (3) LICENSURE
FUNCTIONS
Name - Component - 00
(3) Take all reasonable steps to
conform to all applicable Federal,
State, and local laws and
regulations.
Observations:
Based on review of facility's Patient Safety Plan, review of facility documents and interviews with staff (EMP), it was determined the facility failed to conform to an applicable State law.
Suburban Community Hospital was found to be non-compliant with the following State law:
Medical Care Availability and Reduction of Error (Mcare) Act of Mar. 20, 2002, P.L. 154, No. 13. ..."Section 302. Definitions. ... Infrastructure failure. An undesirable or unintended
event, occurrence or situation involving the infrastructure of a medical facility or the discontinuation or significant disruption of a service which could seriously compromise patient
safety... Section 313. Medical facility reports and notifications ... c) Infrastructure failure reports. --A medical facility shall report the occurrence of an infrastructure failure to the Department within 24 hours of the medical facility's confirmation of the occurrence or discovery of the infrastructure failure. The report to the department shall be in the form and manner prescribed by the department...."
Based on review of the facility's Patient Safety Plan, review of facility documents, and interviews with staff (EMP), it was determined the facility failed to report to the Department that the facility was on Computerized Tomography (CT) scan divert status due to lack of CT staff in seventeen (17) out of eighteen (18) occurrences reviewed from November 2023 through March 2024.
Findings include:
Review on April 1, 2024, of the facility's Patient Safety Plan-PA (SCPA), reviewed December 2023, revealed " ...IV Definitions ... Additional Definitions according to MCARE Act 13, PA ... Infrastructure Failure- An undesirable or unintended event, occurrence of situation involving infrastructure or the discontinuation or significant disruption or a service, which could seriously compromise patient safety ... " Further review revealed " ...B. Internal and External Reporting (MCARE Act 13, PA)...5. Events and Infrastructure Failures - The organization shall report these occurrences to the Patient Safety Authority and Department of Health (DOH) within 24 hours of the confirmation of the occurrence. This report shall be submitted using the PA-PSRS and shall not include the name of any patient or any other identifiable individual information ... "
Review of CT staff schedule for November 2023 through March 2024, revealed seventeen (17) occurrences where CT staff was not available. Those occurrences include:
November 11, 2023 from 7:00 AM to 11:00 PM
November 23, 2023 from 3:00 PM to 11:00 PM,
November 25, 2023 from 7:00 AM to 12:00 PM,
December 2, 2023 from 7:00 AM to 1:00 PM,
December 10, 2023 from 7:00 AM to 7:00 PM,
December 23, 2023 from 7:00 AM to 12:00 PM,
December 25, 2023 from 3:00 PM to 11:00 PM,
December 30, 2023 from 7:00 AM to 7:00 PM,
January 19, 2024 from 7:00 PM to 11:00 PM,
January 21, 2024 from 7:00 AM to 7:00 PM,
February 1, 2024 from 3:00 PM to 11:00 PM,
February 10, 2024 from 7:00 AM to 7:00 PM,
February 17, 2024 from 7:00 AM to 7:00 PM,
February 23, 2024 from 7:00 AM to 7:00 PM,
March 3, 2024 from 7:00 AM to 7:00 PM,
March 16, 2024 from 7:00 AM to 7:00 PM,
March 30, 2024 from 7:00 AM to 7:00 PM.
Interview with EMP3 April 1, 2024, at 2:10 PM, confirmed the facility was on CT divert status due to lack of CT staff during the months of November 2023 through March 2024 as reviewed on staffing schedule and listed immediately above.
Interview with EMP4 on April 1, 2024, at 2:17 PM, confirmed the CT divert occurrences listed above were not reported to the Department.
Plan of Correction: Plan of Correction:
WHO
The hospital Pt. Safety Officer [PSO] is responsible for the corrective action and overall ongoing compliance.
WHAT
The following action(s) will be taken:
1.The site PSO has been remediated as a result of this citation re: this 24-hour infrastructure reporting written notice requirement: discontinuation or significant disruption of a service which could seriously compromise patient safety... Section 302. Definitions. ... Infrastructure failure
WHEN
This remediation was completed on 4/1/24 after discussion with Department of Health [DOH] reviewer.
PA. Patient Safety Reporting System [PA-PSRS] reports for divert events began being routinely reported on 4/2/24 regardless of impact on patient care.
HOW
Ongoing compliance will be sustained by:
1.Completing required notification as stated above within 24 hours of event discovery
1.Erring on side of caution and reporting if potentially necessary.
2.PA-PSRS infrastructure submissions will be audited @ 100% weekly x 1 month by the PSO [May] then monthly x 2 more months [June & July]. The audit will ensure that the recorded divert hours are reported into PA-PSRS.
3. Results of the compliance for reporting the infrastructure failures weekly x 1 month by the PSO [May] then monthly x 2 more months [June & July] will be reported. reported to Pt. Safety Committee.
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 medical records (MR), facility documents, and interviews with staff (EMP), it was determined the facility failed to provide STAT CT scan to a patient in a timely manner.
Findings include:
Review of MR1 on April 1, 2024, revealed a CT angiogram (CTA) was ordered by the physician on November 23, 2023 at 3:53 PM with a STAT level of urgency. Further review of provider notes revealed "...Plan was to get CTA stat but it is unavailable in hospital till 11 pm ..." Continued review of MR1 orders revealed the STAT test was not updated once it was noted the test could not be completed in such manner.
Review of MR1 nursing notes revealed the patient was transported to the in-house CT department at 11:35 PM.
Review of CT staff schedule for November 2023 through March 2024, revealed there was no CT staff in house on November 23, 2023 from 3:00 PM to 11:00 PM.
Request was made via email to EMP4 on April 3, 2024 for facility policy and procedure and/or Medical Staff Rules and Regulations that addressed the turn around time of STAT CT order. None provided.
Interview with EMP3 on April 1, 2024 at 2:10 PM, confirmed hospital did not have CT staff in house on November 23, 2023 from 3:00 PM to 11:00 PM. Further interview with EMP3 confirmed that there was a delay for the patient in MR1 getting a STAT CT scan as ordered.
Interview with EMP4 via email on April 8, 2024, confirmed facility has no definitive turnaround time for STAT CT orders and turnaround time varies depending on acuity of the situation.
Plan of Correction:WHO
The Radiology Director is responsible for the corrective action and overall ongoing compliance.
WHAT
The following action(s) will be taken:
1.The radiology department chair will provide definition for STAT CT turnaround time [TAT] by 5/10/24.
2. This definition will be added as a radiology dept. policy by the radiology dept. director by 5/15/24.
3. A mailing via email will be issued by the med. staff office manager to the medical staff members and the resident physicians via the GME office re: the STAT CT definition by 5/15/24. A read receipt will be tracked to ensure mailing receipt.
4. Radiology reception & CT staff will be educated by department Director re: CT stat definition by 5/15/24
WHEN
1.The effective date of the definition will be 5/15/24
HOW
Ongoing compliance will be sustained by:
1. Radiology Dept. Director will monitor 100% of the STAT CT TAT as follows:
-a weekly avg. TAT will be audited for 4 weeks [May 6—May 27]
2. If compliant, will move to random audit of 20 cases/month for 2 months [June & July]
3. Results reported to Quality Council via the radiology dept. Performance Improvement [PI] report x 3 months then semi-annually. TAT concerns exceeding the average will be reviewed by ED & Radiology dept. chairs
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