QA Investigation Results

Pennsylvania Department of Health
ALLEGHENY VALLEY HOSPITAL
Health Inspection Results
ALLEGHENY VALLEY HOSPITAL
Health Inspection Results For:


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Initial Comments:

This report is the result of an unannounced onsite complaint investigation (PA00052453) completed on June 16, 2021, at Allegheny Valley Hospital. It was determined the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.










Plan of Correction:




482.23(b)(6) STANDARD
SUPERVISION OF CONTRACT STAFF

Name - Component - 00
All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer).

Observations:

Based on a review of facility documents, medical records (MR), and staff (EMP) interview, it was determined the facility failed to ensure the registered nurse (RN) immediately assessed a patient on cardiac monitoring upon notification of a rhythm change.

Findings include:

On June 16, 2021, review of the facility's policy "Remote Cardiac Monitoring" last revised 11/2019, revealed "Policy Scope: This standard applies to all Allegheny Valley Hospital staff or physicians who have clinical contact with our patients. Policy Statement: The purpose of the cardiac monitoring process is to provide monitoring to patients who are at risk for an arrhythmic event that would require intervention. Policy Purpose: 1. Provide a detailed procedure for the application, use and maintenance of remote cardiac monitoring 2. Define criteria for instituting or discontinuation of remove cardiac monitoring ... Guidelines / Procedures: Process for Remote Cardiac Monitoring ... 5. The RN is to immediately assess patient upon notification of rhythm change. ... The RN will document time of notification, assessment of patient, and interventions performed (vital signs, notified MD, RRT initiated). ... "

Review of facility documentation revealed that when the telemonitor technician notified the RN (EMP7) that MR1 was "off monitor," EMP7 asked an aide to check the patient and to place the leads back on the patient.

Review of MR1 revealed the following Nursing note dated June 10, 2021, at 8:50 AM: At 0718 the nurse was notified by the monitor tech that the patient was off the monitor. The nurse instructed the patient care associate to place the patient back on the monitor.

During an interview on June 16, 2021, at approximately 10:30 AM, EMP3 confirmed the documentation in the nursing note for June 10, 2021.




Plan of Correction:

The Chief Executive Officer and Chief Nursing officer are ultimately responsible for this plan of correction.

Allegheny Valley Hospital failed to ensure the Registered Nurse immediately assessed a patient on cardiac monitoring upon notification of a rhythm change.

Upon notification of the event on June 10, 2021, immediate action was taken. A "red alert" was developed by leadership and sent to all departments concerning the event and steps that were to be taken to ensure that this event would not happen again. The "red alert" outlines the critical steps from the remote cardiac monitoring policy that must be followed. All staff were required to read and sign that they had read and understood the message. Within 24 hours, 70% of the staff working with cardiac monitors had signed the "red alert" and completed the attestation. Staff that were on a leave or weekend workers were given instructions that reading and signing was a condition for returning to their shift. By July 21, 2021, 100% of staff caring for Telemetry patients will review the red alert.

June 11, 2021: Within 24 hours, the policy for Remote Cardiac Monitoring had been reviewed with key points in the policy outlining roles and responsibilities and constructed in bullet points for education. Education began on June 11, 2021 with an attestation that each employee had read and signed and understood. By July 21, 2021, 100% of staff caring for Telemetry patients will receive this training.

June 14, 2021: An auditing form was created and put into use on "response time". From the time the monitor tech notified the nurse caring for a particular patient that there was a rhythm change to the time the nurse responded, the policy stated 5 minutes with follow-up actions. Education was completed by 100% of the monitor techs responsible for utilizing this tool. By July 21, 2021, 100% of staff caring for monitored patients will have completed the education. Monitoring and auditing began.

As of June 12, 2021, all staff involved in the incident were interviewed to determine the facts. The interviews were face to face or virtual and a written report was obtained.

June 14, 2021: A Root Cause Analysis was conducted with staff involved in the incident. Leadership also attended. The RCA was conducted by the Patient Safety Officer. Gaps in the process were identified with the root cause being the nurse failed to respond to a call from the monitor tech.

The present remote monitoring policy is being reviewed to clearly define roles, responsibilities, and steps to prevent catastrophic events. Education will start with a completion date of all staff with cardiac monitoring responsibilities on July 21, 2021.

An audit of monitor response is taking place and will continue indefinitely with an expected compliance of 100%. As of today, June 25, 2021, the compliance is 100%.

100% of all staff caring for monitored patients will be educated on the new Remote Cardiac Monitoring policy by July 21, 2021. The new policy will be audited for compliance beginning July 26, 2021. 100% of the patients will be monitored for 3 months and then 30% on a weekly basis for 6 months. At any time if non-compliance is identified, immediate action will be taken.

The new policy, Remote Cardiac Monitoring will be reviewed yearly by all staff caring for patients on a cardiac monitor. This education will become part of yearly competencies.

Audits will be reported to the Manager of Regulatory Affairs on a weekly basis. The Manager of Regulatory Affairs will report to the Senior Leadership on a monthly basis. The Manager of the cardiac units will report compliance at the monthly Performance Improvement Committee on a monthly basis.



Initial Comments:

This report is the result of an unannounced onsite special monitoring investigation completed on June 16, 2021, at Allegheny Valley 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:




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 a review of facility documents, medical records (MR), and staff (EMP) interview, it was determined the facility failed to ensure the registered nurse (RN) immediately assessed a patient on cardiac monitoring upon notification of a rhythm change.

Findings include:

On June 16, 2021, review of the facility's policy "Remote Cardiac Monitoring" last revised 11/2019, revealed "Policy Scope: This standard applies to all Allegheny Valley Hospital staff or physicians who have clinical contact with our patients. Policy Statement: The purpose of the cardiac monitoring process is to provide monitoring to patients who are at risk for an arrhythmic event that would require intervention. Policy Purpose: 1. Provide a detailed procedure for the application, use and maintenance of remote cardiac monitoring. 2. Define criteria for instituting or discontinuation of remove cardiac monitoring ... Guidelines/Procedures: Process for Remote Cardiac Monitoring ... 5. The RN is to immediately assess patient upon notification of rhythm change. ... The RN will document time of notification, assessment of patient, and interventions performed (vital signs, notified MD, RRT initiated). ... "

Review of facility documentation revealed that when the telemonitor technician notified the RN (EMP7) that MR1 was "off monitor", EMP7 asked an aide to check the patient and to place the leads back on the patient.

Review of MR1 revealed the following Nursing note dated June 10, 2021, at 8:50 AM: At 0718 the nurse was notified by the monitor tech that the patient was off the monitor. The nurse instructed the patient care associate to place the patient back on the monitor.

During an interview on June 16, 2021, at approximately 10:30 AM, EMP3 confirmed the documentation in the nursing note for June 10, 2021.







Plan of Correction:

The Chief Executive Officer and Chief Nursing officer are ultimately responsible for this plan of correction.

Allegheny Valley Hospital failed to ensure the Registered Nurse immediately assessed a patient on cardiac monitoring upon notification of a rhythm change.

Upon notification of the event on June 10, 2021, immediate action was taken. A "red alert" was developed by leadership and sent to all departments concerning the event and steps that were to be taken to ensure that this event would not happen again. The "red alert" outlines the critical steps from the remote cardiac monitoring policy that must be followed. All staff were required to read and sign that they had read and understood the message. Within 24 hours, 70% of the staff working with cardiac monitors had signed the "red alert" and completed the attestation. Staff that were on a leave or weekend workers were given instructions that reading and signing was a condition for returning to their shift. By July 21, 2021, 100% of staff caring for Telemetry patients will review the red alert.

June 11, 2021: Within 24 hours, the policy for Remote Cardiac Monitoring had been reviewed with key points in the policy outlining roles and responsibilities and constructed in bullet points for education. Education began on June 11, 2021 with an attestation that each employee had read and signed and understood. By July 21, 2021, 100% of staff caring for Telemetry patients will receive this training.

June 14, 2021: An auditing form was created and put into use on "response time". From the time the monitor tech notified the nurse caring for a particular patient that there was a rhythm change to the time the nurse responded, the policy stated 5 minutes with follow-up actions. Education was completed by 100% of the monitor techs responsible for utilizing this tool. By July 21, 2021, 100% of staff caring for monitored patients will have completed the education. Monitoring and auditing began.

As of June 12, 2021, all staff involved in the incident were interviewed to determine the facts. The interviews were face to face or virtual and a written report was obtained.

June 14, 2021: A Root Cause Analysis was conducted with staff involved in the incident. Leadership also attended. The RCA was conducted by the Patient Safety Officer. Gaps in the process were identified with the root cause being the nurse failed to respond to a call from the monitor tech.

The present remote monitoring policy is being reviewed to clearly define roles, responsibilities, and steps to prevent catastrophic events. Education will start with a completion date of all staff with cardiac monitoring responsibilities on July 21, 2021.

An audit of monitor response is taking place and will continue indefinitely with an expected compliance of 100%. As of today, June 25, 2021, the compliance is 100%.

100% of all staff caring for monitored patients will be educated on the new Remote Cardiac Monitoring policy by July 21, 2021. The new policy will be audited for compliance beginning July 26, 2021. 100% of the patients will be monitored for 3 months and then 30% on a weekly basis for 6 months. At any time if non-compliance is identified, immediate action will be taken.

The new policy, Remote Cardiac Monitoring will be reviewed yearly by all staff caring for patients on a cardiac monitor. This education will become part of yearly competencies.

Audits will be reported to the Manager of Regulatory Affairs on a weekly basis. The Manager of Regulatory Affairs will report to the Senior Leadership on a monthly basis. The Manager of the cardiac units will report compliance at the monthly Performance Improvement Committee on a monthly basis.