This report is a result of an on-site complaint investigation conducted on May 8-10, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc.-Pyramid Pittsburgh, was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this investigation.
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Plan of Correction
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Observations
The facility failed to adhere to procedures for treatment and rehabilitation management in the detoxification level of care.*Facility has a standing medical order that exists for detox patient monitoring by the nursing staff every four (4) hours, to check vital signs and administer an appropriate withdrawal assessment (COWS or CIWA), unless otherwise ordered by the physician.Medical records reviewed indicated that a male client was admitted to detox on 10/30/18 at approximately 6 pm. He was medically assessed again at 9:42 pm, however the next assessment was not conducted until 10:55 am on 10/31/18. Assessments were conducted on 10/31/18 at 3:06 pm and again at 6:44 pm, however no other assessment was documented; this patient was found unresponsive at approximately 1:15 am on 11/1/18 and transported to the hospital after emergency measures were implemented by facility staff and EMT ' s.Facility staff acknowledged that the monitoring procedure was not followed in this case.
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Plan of Correction
An auditing tool has been created for auditing q4 hour vitals, COWS and CIWA. Charge Nurses are responsible for using this auditing tool per shift to monitor all detox clients charts to ensure vitals checks, COWS/CIWA are occurring Q4 hours, unless otherwise specified by a doctors order or as a result of a COWS/CIWA score. Charge Nurses will ensure vitals match doctors orders or COWS/CIWA scores, or as clinically indicated. Nurse Manager will review copies of these audits daily to ensure compliance. Nurse Manager is responsible for meeting individually with a nurse, if a variance is identified. This auditing tool will become effective 6/6/19 and audits will begin per shift on this date. |