QA Investigation Results

Pennsylvania Department of Health
Health Inspection Results
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Initial Comments:
This report is the result of an unannounced offsite complaint investigation (CHL24C009H) completed on February 26, 2024, at Penn State Health Holy Spirit 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:

117.41 (a) LICENSURE

Name - Component - 00
117.41 Emergency patient care
(a) Emergency patient care shall be
guided by written policies and
procedures which delineate the proper
administrative and medical procedures
and methods to be followed in
providing emergency care. These
policies and procedures shall be clear
and explicit; approved by the medical
staff and hospital governing body;
reviewed annually, revised as
necessary; and dated to indicate the
date of the latest review or revision,
or both.


Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to follow their established policy, by failing to document vital signs based on Emergency Severity Index (ESI) levels and within 30 minutes of discharge for one of one medical record reviewed (MR1).

Findings include:

Review of policy "Emergency Department of Standards of Care" with an effective date: March 2023, revealed "... 1. Triage ... c. Assigning the Emergency Severity Index (ESI) rating: Combining information collected from the assessment a triage acuity rating is assigned to the patient utilizing the ESI. ... 2. Assessment: a. Vital Signs: vital signs will be assessed and documented on patients based on their ESI level i. Vital signs include blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. ... c. Level 3 ESI: vital signs will be assessed at a minimum of every 4 hours. d. ... i. ESI levels 1, 2, and 3 will have a full set of vital signs 30 minutes before discharge. ..."

Review of MR1 revealed that the patient arrived in the emergency department on December 27, 2023, with vital signs documented on triage and discharged December 27, 2023, with no further vital signs documented.

Interview via email on February 23, 2024, at 2:24 PM with EMP2 confirmed there should have been repeat vital signs and the informaiton above is correct.

Plan of Correction:

1.Nursing Leadership is responsible for action plan.
2.Emergency Department Standards of Care WS-ED-2 policy reviewed by key stakeholders including nursing services, senior leadership, and regulatory. There will be no updates to policy at this time.
3.Education on policy WS-ED-2: Emergency Department Standards of Care will be provided by ED nursing leadership to RNs, LPNs, and PCAs in the emergency department from 2/15/24-3/12/24. Education will be provided to nursing staff through daily huddles and staff meetings focusing on vital sign frequency per ESI and obtaining vital signs within 30 minutes of discharge. Education will be validated by attendance logs.
4.Audits will be completed by ED nursing leadership/ED Data Analyst. Audit process in place by 3/4/24. All charts for patients discharged from the waiting room/triage area will be audited for documentation in the electronic health record. Audits will include documentation review that vital signs were completed per ESI and vital signs obtained within thirty minutes of discharge. Audits will occur until 90% compliance for three consecutive months is achieved, then transition to random audits as needed. Results of audits will be shared by nursing leadership during the monthly Quality and Regulatory meeting.