QA Investigation Results

Pennsylvania Department of Health
Health Inspection Results
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Initial Comments:

This report is the result of two unannounced onsite complaint investigations (HBG19C009H and HBG19C011H) completed on April 10, 2019, at Lancaster Behavioral Health Hospital. It was determined that the facility was not 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

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The patient has the right to receive care in a safe setting.


Based on a review of medical records and facility documents, and interview with staff, the facility failed to consistently ensure that all patients received care in a safe setting. (MR1). Findings include:

Review of MR1 indicated the patient was readmitted to the facility on 3/23/19 with a history of Major Depression Recurrence Severe. Documentation indicated that the patient, due to past history in the facility and continued attempts to harm themselves or others, was ordered 1:1 supervision. According to the facility policy, "Patient Observation Rounds/Level of Supervision, a specified and dedicated staff member will stay within one arm's length of the patient on 1:1 observation at all times".

Documentation in MR1 and in the statement from the patient's caregiver, EMP1, revealed that during the evening shift on 3/31/19, the patient indicated to the caregiver the need to go to the bathroom. EMP1 took the patient to the bathroom and allowed the patient to close the curtain to offer privacy. Minutes later when the caregiver realized that there was no noise coming from the bathroom, the caregiver found the patient on the floor with two socks tied around the patient's neck. The patient was not breathing and a code was called.

On 4/10/19, interview with EMP2 revealed that the caregiver should have maintained direct observation of MR1 and not permitted the curtain to be pulled thus blocking the ability to continuously visualize the patient. Interview with other staff who provide direct care, EMP3 and EMP4, revealed that when staff are assigned to provide 1:1 supervision, they must stay at an arm's length at all times.

Further interview with staff, EMP3, on 4/10/19, revealed that all staff have been asked to carry walkie talkies when on duty. Walkie talkies are available at the nurses' station and are used as a means to communicate with other staff and/or if help is needed. According to EMP3, walkie talkies are typically used by staff but they are not always reliable. Staff have reported that the devices do not always hold the charge for the entire shift and little notice is given before the charge is gone. According to the interview with EMP1, this caregiver did not have a walkie talkie the evening of 3/31/19. Interview with EMP5 revealed that the facility did not have a policy regarding the use of walkie talkies and there was no evidence that the use of the devices or the consistency of the equipment was being monitored.

Plan of Correction:

1. On 4/12/2019, Lancaster Leadership staff instituted enhanced leadership and safety rounding which includes: a)Involvement of managerial and department leads as well as house supervisors, b)Targeted presence on all units to provide support and ongoing re-education as needed c)Retraining with all identified participants to review expectations d)Those that could not attend the training will receive training before completing rounds. e)Data collected from Leadership Rounds will be audited by The Director of Risk Management/Performance Improvement at 100% in order to identify any needed areas of improvement that were identified during the rounding process.

2. Training on the requirements and parameters of a 1:1 began immediately following the visit and was completed on 4/26/2019.
a)Policy changes were made to include more direct language about the maintenance of arm length's in all circumstances. The policy was reviewed as part of the training.
b) 1:1 and all high risk patients are reviewed during leadership/safety rounds, during change of shift, daily in Flash Report and daily by the RN and Physician staff to monitor for any changes.

3. Training on the use of Workstation on Wheels (WOW) began on 4/22 and concluded on 4/26/2019. For those staff members that were not able be trained due to in availability, training will be required before returning for their next worked shift. a)Training targeted the use of the WOW cart. Specifically, for the purposes of patient and staff safety, the WOW carts will only be used in patient care areas for medication administration. b) In addition, appropriate storage of the WOW carts out of patient care areas to ensure they do not present a safety risk to staff or patients.

4. On 4/15, the facility implemented a new 24 hour internal shift report document. This document is an easy and targeted way to communicate pertinent information such as incident reports, patient needs (blocked beds), census and walkie talkie checks. House supervisors are responsible for completing and sending the report internally every 24 hours.

5. All new walkies were ordered on 4/17/19, delivered on 4/18/19, tested on 4/22 and distributed to the units on 4/23/2019. The new walkies have factory charging bases that have light indicators for quick and easy verification that the device is charging. This particular model has a 5 watt output with a range capacity of 36 miles with better reception in comparison to the initial models ordered.

6. Walkies are checked daily by the House Supervisor/ designee with this information documented on shift assignment sheet. a) Additionally, walkie talkies remain part of monthly environmental rounds conducted by the Director of Plan Operations c)Work order system auto-generates reminders to The Director of Plant Operations and team members to check all walkie talkies on the 15th of each month in additional to the monthly environmental rounds b)Replacement walkies are always available

7. There is a policy on walkie talkies. Recently, the title was changed to "Communication Systems" in an effort to align with the content of the policy

8. New Employee Orientation on Suicide Prevention, trained by The Director of Clinical Services, was amended to include discussion of the walkie talkies and safety/security of the WOW carts. Relevant questions added to the competency post test. This was implemented on 4/22/2019.

482.23(b) STANDARD

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The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.


Based on review of facility documentation and interview with staff, the facility failed to provide documentation that showed an accurate count of personnel who worked on each unit . Findings include:

On 4/10/19, interview with staff, EMP3 and EMP4, revealed that during the evening shift of 3/31/19, two staff members who had been assigned to Unit 3, needed to leave the facility to accompany patients to the hospital. In addition, a third staff member, EMP1, left the facility prior to the end of the shift. Review of the facility's assignment sheet for that unit on 3/31/19, revealed that this change in staffing pattern was not reflected on the sheet. According to EMP4, changes are not typically made to the sheet when a staff leaves or is added to the staffing complement. With three less staff for that shift, according to the assignment sheet, the remaining three staff, were responsible for the care of 22 patients.

Interview with EMP5 revealed that the facility did not have a policy on how to use the assignment sheets including what was necessary to be done if the staffing complement changed.

Plan of Correction:

1. There was an active policy in place titled "Patient Care Shift Assignments." This policy was amended slightly and approved through Medical Executive Committee on 4/25/2019 to be reflective of the information that is being collected on the shift assignment sheet.

2. Training on the use of the assignment sheet led by RN Leadership began on 4/22/19 and was completed on 4/26/2019. For those staff members that were not able be trained due to in availability, training will be required before returning for their next worked shift. Training focused on a)The need for dynamic updates to the assignment sheet if there are changes b)Requirements of the form c)Responsibly d)Walkie Talkie checks and e)Review of the aforementioned policy

3. Assignment Sheets will be audited by Chief Nursing Officer and RN Leadership to ensure proper completion, including dynamic updates to reflect patient care assignments at any given time. Chief Nursing Officer and RN leadership will provide re-education and disciplinary action as needed and identified through this audit process.