390046 08/30/2019 york hospital 1001 south george … · prefix tag pennsylvania department of...
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PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Pennsylvania Department of Health
P 0000 P 0000 0.00INITIAL COMMENT
This report is the result of an unannounced onsite special monitoring visit completed on August 22, 23 and 30, 2019, at York 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.
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(X6) DATE:TITLE:LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
IF CONTINUATION SHEET Page 1 of 431DID11State Form
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PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Pennsylvania Department of Health
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103.4 (3) FUNCTIONS
(3) Take all reasonable steps to conform to all applicable Federal, State, and local laws and regulations.
This REGULATION is not met as evidenced by:
Completion
Date:
10/14/2019Status:APPROVEDDate:10/03/2019
The WellSpan Health Corporate Patient Safety Officer and the York Hospital Patient Safety Officer (PSO) will amend Policy 602, Adverse Event Response, to reinforce the necessity of timely reporting of events. In accordance with 40 P.S. § 1303.313(a), upon confirmation of an event that qualifies as a serious event, York Hospital's PSO or designee will notify the Department of Health (DOH) and the Patient Safety Authority (Authority) within 24 hours. The submission to DOH and the Authority will be updated with supplemental information as it becomes available. The report will not be unduly delayed while determining what systems or errors contributed to the event. The revised policy will be reviewed at the York Hospital Quality Performance Improvement Committee at their next meeting and will be presented to the York Hospital Board for approval. In addition, policy training materials on the electronic Learning Management System (LMS) have been updated to emphasize the importance of timely
IF CONTINUATION SHEET Page 2 of 431DID11State Form
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PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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reporting.New Emergency Department (ED) staff will be educated on the policy and the importance of timely reporting at orientation. All ED staff will be required to undergo retraining via the LMS by 10/14/19. Documentation of the education will be maintained in each employee's LMS file.On 9/30/19, the York Hospital Leadership Team was reeducated regarding the definitions of Serious Events, Infrastructure Failures and Incidents and the urgency around reporting these to DOH and the Authority. Attendance was taken at the meeting. Leaders who were not in attendance will be provided with the PowerPoint presentation and handout by 10/11/19. By 10/14/19, the PSO will provide retraining to the ED charge and flow coordinators regarding ED-specific Serious Events, Infrastructure Failures and Incidents and the urgency around reporting these to DOH and the Authority.The PSO will audit the recording of
IF CONTINUATION SHEET Page 3 of 431DID11State Form
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PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
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SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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serious events in the SRS and the timing of notification to DOH and Authority. The PSO will meet monthly with the Chief Nursing Office (CNO) to review the results. The CNO will be responsible for monitoring this corrective action and the ongoing plan. The CNO will report the results to the York Hospital president monthly, and to the York Hospital Quality Performance Improvement Committee and to the York Hospital Board of Directors on a quarterly basis.
IF CONTINUATION SHEET Page 4 of 431DID11State Form
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IDENTIFYING INFORMATION)
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Pennsylvania Department of Health
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Based on a review of facility documents, medical records (MR) and interview with staff (EMP), it was determined that York Hospital was not in compliance with the following State Law:Act 13 of 2002 Medical Care Availability and Reduction of Error (MCARE) Act 13 of 2002 Section 313. Medical facility reports and notifications. (a) Serious event reports. - A medical facility shall report the occurrence of a serious event to the Department and the Authority within 24 hours of the medical facility's confirmation of the occurrence of the serious event.
The facility failed to notify the Department within 24 hours of confirmation of a serious event for one of one event reviewed (MR1).
Findings include:
York Hospital ... Patient Safety Program revealed "... I. Purpose of the Program: Abundant evidence indicates that most human errors are symptoms of underlying systems failure, not personal failures. The
IF CONTINUATION SHEET Page 5 of 431DID11State Form
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PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
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SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Patient Safety Program will ensure that a culture of patient safety, blameless reporting of patient safety concerns, coupled with systematic, coordinated and continuous approach to patient safety are the standards of every employee ...III. Key Definitions ... Serious Event- An event, occurrence, or situation involving the clinical care of a patient in a medical facility(hospital, ambulatory surgery facility, or birthing center) that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health services to the patient ... D. External Reporting: MCARE ACT the hospital shall submit a Serious Event report as defined in Act 13 or Chapter 51 to the Patient Safety Authority and the Department of Health no later than 24-hours after confirmation of the occurrence by the Patient Safety Officer or designee. This report will not be delayed for peer review or other quality investigating activities. ..."
An interview conducted on August 27, 2019, with EMP7 confirmed that a Serious Event report was
IF CONTINUATION SHEET Page 6 of 431DID11State Form
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IDENTIFYING INFORMATION)
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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not entered until after the facility conducted a Root Cause Analysis.
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IDENTIFYING INFORMATION)
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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103.22 (b)(6) IMPLEMENTATION
(6) The patient has the right to expect emergency procedures to be implemented without unnecessary delay.
This REGULATION is not met as evidenced by:
Completion
Date:
10/18/2019Status:APPROVEDDate:10/04/2019
By 10/7/14 the ED will develop standard work to ensure that all patients arriving by ambulance will be met by the flow coordinator or charge nurse and will be directly bedded or taken directly to triage. If the patient has an acuity of ESI 2 or greater, they will be placed in a bed for additional evaluation or treatment.
All flow coordinators and charge nurses will be educated on the new standard work prior to 10/7/19.Beginning on 10/7/19, and daily thereafter, the ED nurse managers or designee will audit all ESI 2 patients to determine the time of arrival to the time of bed to the time the patient sees a physician or APC. The CNO or designee will review the audit results on a daily basis until reliability is demonstrated.The conduct of the nurses involved with this incident has been peer reviewed and evaluated. Both were managed in accordance with human resources policies.
IF CONTINUATION SHEET Page 8 of 431DID11State Form
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SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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To ensure that patients receive triage in accordance with procedure, staffing has been enhanced to ensure 24/7 triage coverage. The ED nurse managers and director developed a plan to ensure a triage RN, pivot RN and a lobby nurse are scheduled 24/7. Eight traveling nurses have been contracted. These nurses will be in place by 10/24/19.
The lobby nurse will make rounds with the assigned ENA to assess vital signs, pain and comfort level of all patients on a timely basis, according to their ESI level. The lobby nurse or assigned ENA will round on all patients in the lobby to confirm their presence. No patient will be taken off the tracking board without physical confirmation of their departure. Beginning on 8/21/19, the ED nurse managers provided 1:1 education to all nurses who can be assigned to the pivot, triage, or lobby RN role. Thirty-eight (38) nurses (100% eligible) were educated using 1:1
IF CONTINUATION SHEET Page 9 of 431DID11State Form
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SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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instruction with teach back. This included re-education regarding standard work and emphasis on the importance of medical record documentation. Education was completed by the ED nurse managers on 9/9/2019. Documentation of the education will be maintained in each nurse's file in the ED. An audit plan was developed to ensure that ED staff are following standard work. Beginning on 9/9/19, ED protocols are reviewed with every new ED RN employee during orientation and as part of triage and pivot role orientation.
Beginning on 10/1/19, on a daily basis, the ED nurse managers or designee will audit to assure that a triage RN, pivot RN and lobby nurse are scheduled and in place. Auditing will continue daily. The audit results will be reviewed with the Senior Nursing Director on a weekly basis. The Senior Nursing Director will share the audit results with the CNO on a monthly basis.
IF CONTINUATION SHEET Page 10 of 431DID11State Form
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IDENTIFYING INFORMATION)
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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The CNO or designee will report the results to the York Hospital president monthly and to the York Hospital Quality Performance Improvement Committee and York Hospital Board of Directors on a quarterly basis.
IF CONTINUATION SHEET Page 11 of 431DID11State Form
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SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Based on a review of facility documents, medical record (MR1), and staff interviews (EMP), it was determined that York Hospital failed to implement emergency procedures without unnecessary delay for one medical record reviewed.
Findings include:
York Hospital policy Nursing Documentation Standards, no revision date. "I. Purpose: 1. To ensure that clinical data relevant to each patient's chief complaint or mechanism of injury and the patient's ongoing status is obtained and recorded in the appropriate area of the medical record and at the appropriate time intervals. 2. To validate current practice as related to hospital-wide and regulating agency performance improvement initiatives. II. Policy Statement: The Emergency Service Line is committed to providing safe, timely, effective, efficient and equitable care. Documentation is a crucial aspect of this care. Standards for frequency of ED nursing documentation of clinical data incorporate the
IF CONTINUATION SHEET Page 12 of 431DID11State Form
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SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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patient chief complaint, interventions needed and the patient's current status. Acuity changes during a patient's course of EC care must be documented by the primary nurse including rationale for change in acuity. Emergency Services strives to comply with patient care standards set by accrediting bodies in accordance with accepted national Emergency Nursing practice benchmarks ... g. Mark "triage complete" (stops triage). h. enter GCS. Lobby (if patient is still in Lobby) : a. Vital signs q2 hours despite acuity level. b. Hourly rounding: pain, personal needs, protection and presentation ... Per acuity and clinical assessment but no less frequently than: a. Hourly rounding: pain, personal needs, protection and presentation (ENA). b. Acuity 1: VS q 15 minutes x 4, then q 1 hour x4, then if stable q2. Acuity 2: VS q 1 hour x 4, then if stable q2. Acuity 3; VS q2 x 2, then if stable q4...f. Any abnormal vital signs should be confirmed manually and reported to the primary RN and provider ... . "
York Hospital policy Standard Work Instructions;
IF CONTINUATION SHEET Page 13 of 431DID11State Form
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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Standard of Care, Rounding in ED: Last Updated 12-4-2017; York Hospital; ED. "Trigger: Patient LOS (length of stay) in WR(waiting room) reaches 1 hour without bed assignment ... Role ENA/ECA/RN ... Purpose: To assure standardized process for rounding on patients in the Waiting Room. Process Steps: 1. At the top of each hour, identify patients in Waiting Room for bed assignment greater than one hour. 2. Call patient's name. Walk to patient's location, introduce yourself, verify ID band. 3. Document patient's initials, chief complaint. ESI and current wait time on Rounding Log ... 5. Ask patient how they are feeling, increase/improvement in pain? Evaluate appearance - now diaphoretic, pale, change in LOC. Document findings on Rounding Sheet. ... ."
York Hospital policy ENA assigned as Pivot ENA. "Purpose: Why are we doing this?? To standardize the various ENA and ECA roles within the ED. Completed: At the beginning of your assigned shift as Pivot, you will print the Tracking Board of the Lobby. Both the oncoming and the off-going ENA
IF CONTINUATION SHEET Page 14 of 431DID11State Form
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SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
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STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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will round on all patients that are in the Lobby. You will identify each patient and compare the patient's arm band to the list of patients from the Tracking Board ... ."
The review of the medical record (MR1) revealed "ED Care Timeline...8/16/2019 Time 09:59 Event: Patient arrived in ED.09:59:28 Emergency encounter created. 09:59:38 Arrival Complaint: Nausea. 10:13:15 ED Triage Notes: Pt to ER via ems for n/v, Addendum: dizziness since last night. Hx of vertigo. ... pts temp is low. Having difficulty getting pulse ox. 10:14:53 Onset: Last night. ...10:15 Sepsis Screening: Does the patient have any of the ?: No signs/symptoms.10:15 Patient Acuity 3... 10:15:19 Triage completed. 10:20 Patient Acuity: 2. 10:25:07 Vital Signs: Heart Rate 120!, Resp: 28!, BP: 115/89.
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SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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12:05:58 ED LWBS (left without being seen). ED Disposition set to LWBS after Triage ...12:20 Acuity/Destination. Patient Acuity: 1. 12:25 Code Start: code initiated upon pts arrival to room ... 13:31 Deceased Patient's Information: Pronounced by ... 14:29 ED Note Addendum: At approximately 1225 Pt was brought to room 306 after being found unresponsive in ED Lobby. When this RN entered room resuscitation efforts were under way ... ."
MR1 failed to reveal any documented evidence that anyone had completed rounding while MR1was waiting in the ED Waiting area. There is documentation that MR1 arrived via ambulance at 09:59, and was removed from the ED Tracking Board at 12:05:58, as LWBS, when MR1 failed to respond to their name being called three times. MR1 revealed that none of the applicable ED protocols were initiated on the patient.
IF CONTINUATION SHEET Page 16 of 431DID11State Form
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A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Continued from page 16P 0351 0351P
York Hospital policy ED Vomiting/Diarrhea. "Protocol: For adults presenting with vomiting and/or diarrhea. Comprehensive metabolic panel- STAT... CBC and differential- Stat ...
ED Syncope Protocol: For adults presenting after syncope or near syncope episode: Perform bedside blood glucose ... Comprehensive metabolic panel-Stat. CBC and differential-Stat. ECG 12-lead ...
ED Sepsis Protocol: Note to Providers: For adults who meet Sepsis/SIRS criteria: Nasal Cannula - Oxygen Therapy PRN Stat ... Notify provider: For consideration of additional orders ... Pulse oximetry Stat ... Telemetry monitoring ED Only Yes Stat ... APTT - Stat ... Blood culture- 2 sets ... CBC and differential-Stat ... Comprehensive metabolic panel- Stat ... ED SIRS/Sepsis Screening Initiated ..."
Observation of the security camera footage revealed
IF CONTINUATION SHEET Page 17 of 431DID11State Form
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SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
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(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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the patient (MR1) had their oxygen discontinued, had been removed from the ambulance stretcher into a wheelchair and placed in the Waiting Room by EMS (Emergency Medical Service personnel) and left in front of a Triage Room. That Triage Room was not scheduled to be used that day after 11:00 AM. EMS personnel was observed speaking with the Pivot Nurse. The patient was not taken over to the Pivot Nurse's desk, nor did the Pivot Nurse get out of the chair, the nurse was not observed to speak with the patient or to examine the patient. The vital signs were taken by the Nursing Assistant. At no time was any staff observed to complete Rounding on MR1 as per their Rounding policy. No movement by the patient was noted from approximately 11:09 AM until approached by staff at 12:20 PM. Staff was observed to have walked past the patient approximately 12 times and staff were observed coming out of the Triage Room approximately seven times. It was observed that some of the staff were within 1-2 feet of the patient (MR1). At 12:20 PM the patient (MR1) was approached by a staff person and taken to a room
IF CONTINUATION SHEET Page 18 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
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(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
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(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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within the Emergency Department.
A review of ED documentation revealed that the facility admitted two other patients that were triaged as ESI 4 (a less acuity score) after MR1 was placed in the Waiting area. Both patients presented after MR1, they were triaged, examined by a provider and discharged while MR1 was still in Waiting area.
An interview on August 28, 2019, with EMP8 revealed that the patient (MR1) had been removed from the Tracking Board after the patient failed to respond when the patient's name was called three different times. EMP8 stated that staff should have gone around the Waiting area and looked for the patient but did not.
A interview conducted on August 28, 2019, with EMP7 revealed that the sepsis alert was not triggered but it should have been. EMP7 explained
IF CONTINUATION SHEET Page 19 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
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(X5)COMPLETE
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PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
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IDENTIFYING INFORMATION)
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(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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that since the patient's temperature was not entered into the medical record, the alert would not have triggered. The sepsis protocol was not initiated on MR1, and the patient was not rounded on per our policies.
P 0361 P 0361 0.00
IF CONTINUATION SHEET Page 20 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
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(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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103.22 (b)(16) IMPLEMENTATION
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.
This REGULATION is not met as evidenced by:
Completion
Date:
10/14/2019Status:APPROVEDDate:10/04/2019
This event has been taken extremely seriously at all levels of the organization. The York Hospital and WellSpan Health Boards were made aware. Weekly calls and meetings regarding this matter, status and progress with York Hospital Board Executive Committee have occurred and will continue until the plan of correction is approved and audits are reliable. The board has oversight and is holding the leadership team accountable for results.
To ensure that patients in the ED waiting room are all accounted for, the York Hospital Emergency Department (ED) has created reliable staffing for the roles of Pivot Nurse, Triage Nurse, and Lobby Nurse on a 24/7 basis. The ED Nursing Documentation Standards policy will be updated by 10/14/19 to reflect the new roles and their documentation responsibilities. Nurses have been reassigned in the department, to ensure that staff are providing 24/7 coverage in the Pivot and Triage areas. A nurse has been
IF CONTINUATION SHEET Page 21 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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Continued from page 21P 0361 0361P
assigned to reassess patients in the lobby area, whenever the length of stay in the lobby exceeds one hour. The ED nurse managers and director developed a plan to ensure a triage RN, pivot RN and a lobby nurse are scheduled 24/7. Fifteen traveling nurses have been contracted. Six of these positions are filled. We continue to recruit for the remainder of the positions.
The lobby nurse will make rounds with the assigned ENA to assess vital signs, pain and comfort level of all patients on a timely basis, according to their ESI level. The lobby nurse or assigned ENA will round on all patients in the lobby to confirm their presence. No patient will be taken off the tracking board without physical confirmation of their departure. Beginning on 8/21/19, the ED nurse managers provided 1:1 education to all nurses who can be assigned to the pivot, triage, or lobby RN role. Thirty-eight (38) nurses (100% eligible) were educated using 1:1
IF CONTINUATION SHEET Page 22 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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Continued from page 22P 0361 0361P
instruction with teach back. This included re-education regarding standard work and emphasis on the importance of medical record documentation. Education was completed by the ED nurse managers on 9/9/2019. Documentation of the education will be maintained in each nurse's file in the ED. An audit plan was developed to ensure that ED staff are following standard work. Beginning on 9/9/19, ED protocols are reviewed with every new ED RN employee during orientation and as part of triage and pivot role orientation.
Beginning on 10/1/19, on a daily basis, the ED nurse managers or designee will audit to assure that a triage RN, pivot RN and lobby nurse are scheduled and in place. Auditing will continue daily. The audit results will be reviewed with the Senior Nursing Director on a weekly basis. The Senior Nursing Director will report the audit results with the CNO on a monthly basis.
IF CONTINUATION SHEET Page 23 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Continued from page 23P 0361 0361P
To improve ED throughput, York Hospital has taken further steps to open additional medical/surgical beds to increase capacity to care for inpatients, thus freeing up beds in the ED to assess and treat patients presenting in the ED. York Hospital received the reinstatement of these additional inpatient beds from the Division of Safety Inspection on 9/9/19.
York Hospital ED town hall meetings were held on 9/4/19 and 9/5/19 to discuss the important aspects of this event and the importance of a culture of safety. Hospital administration reinforced that staff, regardless of role, is expected to speak up when they have a concern or question about tasks/orders/treatment, etc. All employees are empowered and obligated to speak up and "stop the line" when they have a concern about a patient or a safety issue. Ninety-Eight (98) staff members attended the four (4) town hall
IF CONTINUATION SHEET Page 24 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
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(X5)COMPLETE
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PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Continued from page 24P 0361 0361P
meetings. For those who were unable to attend the town hall meetings, the content of the meetings was discussed during daily change of shift huddles for two (2) weeks, starting on 9/9/19 and continuing through 9/22/19. The ED weekly newsletter (dated 9/13/19) also contained the town hall meetings content, with a focus on the need for staff to speak up about any patient related concern.
The CNO will be responsible for monitoring this corrective action and the ongoing plan. The CNO or designee will report the results to the York Hospital president monthly, and to the York Hospital Quality Performance Improvement Committee and the York Hospital Board of Directors on a quarterly basis.
IF CONTINUATION SHEET Page 25 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Continued from page 25P 0361 0361P
Based on a review of facility documents, medical record (MR), security camera footage, and staff interview (EMP), it was determined that York Hospital failed to implement good management techniques by failing to ensure that patients in the Emergency Department were monitored and received treatment within a timely manner.
A review of facility policy revealed Nursing Documentation Standards, no revision date. "I. Purpose: 1. To ensure that clinical data relevant to each patient's chief complaint or mechanism of injury and the patient's ongoing status is obtained and recorded ... Acuity changes during a patient's course of EC care must be documented by the primary nurse including rationale for change in acuity ... IV. Procedure: 1. EVERY PATIENT a. Must have a GCS (Glasgow coma scale) and vital signs within 10 minutes of arrival. b. If the patient's condition changes: document a repeat assessment, modify acuity level and notify the assigned provider and flow coordinator ... d. ED Notes and Assessments are performed upon assuring care, change in
IF CONTINUATION SHEET Page 26 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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condition and significant events ... 2. PIVOT ... a. RN completes travel screen enters brief ED triage Note, selects ESI level and GCS. b. ENA(Emergency Nursing Aid)/ ECA(Emergency Care Assistant)/ RN obtains vital signs using vital signs machine and scans them into EHR(electronic medical records system, EPIC). c. ENA/ECA immediately notifies RN of abnormal values ... e. Complete Falls Risk, Sepsis Screen, Suicide Risk, Abuse Indicators. ... a. Vital signs q2 hours despite acuity level. b. Hourly rounding: pain, personal needs, protection and presentation. c. ENA updates RN with changes in patient condition or increase in pain ...f. Any abnormal vital signs should be confirmed manually and reported to the primary RN and provider ... . "
A review of policy Standard Work Instructions; Standard of Care, Rounding in ED: Last Updated 12-4-2017; York Hospital; ED; "Trigger: Patient LOS (length of stay) in WR(waiting room) reaches 1 hour without bed assignment ... Role
IF CONTINUATION SHEET Page 27 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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Continued from page 27P 0361 0361P
ENA/ECA/RN ... Purpose: To assure standardized process for rounding on patients in the Waiting Room. Process Steps: 1. At the top of each hour, identify patients in Waiting Room for bed assignment greater than one hour. 2. Call patient's name. Walk to patient's location, introduce yourself, verify ID band. 3. Document patient's initials, chief complaint. ESI and current wait time on Rounding Log ... 5. Ask patient how they are feeling, increase/improvement in pain? Evaluate appearance - now diaphoretic, pale, change in LOC. Document findings on Rounding Sheet. 6. Ask patient if there is anything they need. Examples - help to bathroom, a blanket, if vomiting offer a new basin or a washcloth. Document on Rounding Log as appropriate. ... 8. Obtain and chart VS if greater than 2 hours since last VS or for change in patient condition. 9. Explain Pivot RN location and instruct patient and/or visitor to notify RN of any concerns or questions. ..."
A review of MR1 revealed that the patient was
IF CONTINUATION SHEET Page 28 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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removed from the Tracking Board at 12:05:58. Further review revealed that the patient was found at 12:20, unresponsive in the ED Lobby (waiting room).
An interview conducted on August 27, 2019 with EMP8 revealed that the Emergency Department (ED) was at capacity, with patients on "medical hold", meaning that there were patients still in the ED waiting for an admission bed. The Pivot Nurse was doing both Pivot and Triage duties between 7:00 AM and 11:00 AM, as they did not have another nurse available.
P 1531 P 1531 0.00
IF CONTINUATION SHEET Page 29 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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Continued from page 29P 1531 1531P
115.33 (a) ENTRIES
115.33 Entries
(a) All significant clinical information pertaining to a patient shall be incorporated in his medical record.
This REGULATION is not met as evidenced by:
Completion
Date:
10/14/2019Status:APPROVEDDate:10/04/2019
The conduct of the nurses involved with this incident has been peer reviewed and evaluated. Both were managed in accordance with human resources policies.
Per York Hospital policy Nursing Documentation Standards, every patient's chief complaint and vital signs will be recorded in the EHR. As part of the new work flow training, all nurses will be re-educated regarding standard work, with emphasis on the importance of medical record documentation. Beginning on 8/21/19, the ED nurse managers provided 1:1 education to all nurses who can be assigned to the pivot, triage, or lobby RN role. Thirty-eight (38) nurses (100% eligible) were educated using 1:1 instruction with teach back. This included re-education regarding standard work and emphasis on the importance of medical record documentation. Education was completed by the ED nurse managers on 9/9/2019.
IF CONTINUATION SHEET Page 30 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Continued from page 30P 1531 1531P
Documentation of the education will be maintained in each nurse's file in the ED. An audit plan was developed to ensure that ED staff are following standard work. Beginning on 9/9/19, ED protocols are reviewed with every new ED RN employee during orientation and as part of triage and pivot role orientation.
The CNO will be responsible for monitoring this corrective action and the ongoing plan. The CNO or designee will report the results to the York Hospital president monthly, and to the York Hospital Quality Performance Improvement Committee and the York Hospital Board of Directors on a quarterly basis.
IF CONTINUATION SHEET Page 31 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Continued from page 31P 1531 1531P
Based on review of facility policy, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure all significant clinical information pertaining to a patient shall be incorporated in the medical record for one of 11 medical records reviewed (MR1).
Findings include:
York Hospital policy Nursing Documentation Standards "I. Purpose: 1. To ensure that clinical date relevant to each patient's chief complaint or mechanism of injury and the patient's ongoing status is obtained and recorded in the appropriate area of the medical record and at the appropriate time intervals ... ."
York Hospital policy Standard Work Instructions; Standard of Care, Rounding in ED: Last Updated 12-4-2017; York Hospital; ED. "Trigger: Patient LOS (length of stay) in WR(waiting room) reaches 1 hour without bed assignment ... Role ENA/ECA/RN ... Purpose: To assure standardized
IF CONTINUATION SHEET Page 32 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Continued from page 32P 1531 1531P
process for rounding on patients in the Waiting Room. Process Steps: 1. At the top of each hour, identify patients in Waiting Room for bed assignment greater than one hour. 2. Call patient's name. Walk to patient's location, introduce yourself, verify ID band. 3. Document patient's initials, chief complaint. ESI and current wait time on Rounding Log ... 5. Ask patient how they are feeling, increase/improvement in pain? Evaluate appearance - now diaphoretic, pale, change in LOC. Document findings on Rounding Sheet. ... ."
A review of security camera footage for August 16, 2019, revealed that MR1 presented to the ED via ambulance at approximately 09:58. Vital signs were observed to be obtained by staff.
MR1 failed to reveal any documented evidence of the vital signs that were obtained on August 16 at 09:58, nor was there any documented evidence that anyone had completed rounding while MR1 was waiting in the Lobby (waiting area)
IF CONTINUATION SHEET Page 33 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Continued from page 33P 1531 1531P
An interview on August 28, 2019, with EMP8 revealed that the patient (MR1) had been removed from the Tracking Board after the patient failed to respond when the patient's name was called three different times. EMP8 stated that staff should have gone around the Waiting area and looked for the patient but did not.
An interview conducted on August 30, 2019, with EMP8 confirmed that the vital signs were obtained but were not documented on the medical record, and that MR1 does not contain any documentation that rounding was completed on this patient while they were in the Waiting area.
IF CONTINUATION SHEET Page 34 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Continued from page 34P 1531 1531P
P 1702 P 1702 0.00
IF CONTINUATION SHEET Page 35 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Continued from page 35P 1702 1702P
117.1 (b) PROVISION OF SERVICES
117.1 (b) Where there is an emergency service, it shall provide prompt examination or treatment, or both, to all persons who come or are brought into the hospital in need of such treatment, irrespective of ability to pay. Such treatment shall be of the highest type consistent with the facilities available and with the standards established in the medical community of which the hospital is a part.
This REGULATION is not met as evidenced by:
Completion
Date:
10/14/2019Status:APPROVEDDate:10/04/2019
By 10/7/19 the ED will develop standard work to ensure that all patients arriving by ambulance will be met by the flow coordinator or charge nurse and will be directly bedded or taken directly to triage. If, after triage evaluation, the patient has an acuity of ESI 2 or greater, they will be placed in a bed for additional evaluation or treatment.
All flow coordinators and charge nurses will be educated on the new standard work prior to 10/7/19.
Beginning on 10/7/19, and daily thereafter, the ED nurse managers or designee will audit all ESI 2 patients to determine the time of arrival to the time of bed to the time the patient sees a physician or APC. The CNO or designee will review the audit results on a daily basis until reliability is demonstrated.
The lobby nurse will make rounds with the assigned ENA to assess vital signs, pain and comfort level of all patients on a timely basis,
IF CONTINUATION SHEET Page 36 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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Continued from page 36P 1702 1702P
according to their ESI level. The lobby nurse or assigned ENA will round on all patients in the lobby to confirm their presence. No patient will be taken off the tracking board without physical confirmation of their departure. Beginning 10/1/19 and weekly thereafter, this process will be audited to ensure that the assessments are performed and documented. The Senior Nursing Director will review the audits on a weekly basis and will discuss the results with the CNO on a monthly basis.
The CNO or designee will report the results to the York Hospital president monthly and to the York Hospital Quality Performance Improvement Committee and York Hospital Board of Directors on a quarterly basis.
IF CONTINUATION SHEET Page 37 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Continued from page 37P 1702 1702P
Based on a review of facility policy, medical records, security camera footage and staff interviews (EMP), it was determined that York Hospital failed to provide a medical screening examination to a patient that presented via ambulance to their Emergency Department (MR1).
Findings include:
York hospital policy EMTALA, dated 1/18, "... Definitions: ... d) Emergency Medical Condition means: (i) A medical condition manifesting itself by acute symptoms or sufficient severity (including severe pain, active labor, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: (1) Placing the health of the individual ... in serious jeopardy; (2) Serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part; ... e) Qualified Medical Providers are: (i) In the Emergency Department: (1) Physicians, including house staff under direct attending supervision. (2)
IF CONTINUATION SHEET Page 38 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Continued from page 38P 1702 1702P
Advanced Practice Clinicians (APC) incudes (Certified Nurse Midwives, Nurse Practitioners, and Physicians Assistant ... Responsibilities of Hospital, Hospital Personnel, and Physicians: (a) Medical Screening Exam (MSE): 1. When an individual comes to the hospital concerned that they may have an emergency medical condition and requests medical care, the hospital must provide for an appropriate MSE within the capability of the Emergency Department, including ancillary services routinely available to the Emergency Department to determine whether an Emergency Medical Condition exists ... 2. The MSE is to be provided by Qualified Medical Personnel that have been designated as qualified medical personnel ... 3. Individuals coming to the Emergency Department must be provided an MSE beyond initial triage. ... ."
Medical record (MR1) revealed "ED Care Timeline ...8/16/2019 Time 09:59 Event: Patient arrived in ED.
IF CONTINUATION SHEET Page 39 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
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Continued from page 39P 1702 1702P
09:59:28 Emergency encounter created. 09:59:38 Arrival Complaint: Nausea. 10:13:15 ED Triage Notes: Pt to ER via ems for n/v, Addendum: dizziness since last night. Hx of vertigo. ... pts temp is low. Having difficulty getting pulse ox. 10:14:53 Onset: Last night. ...10:15 Sepsis Screening: Does the patient have any of the ?: No signs/symptoms.10:15 Patient Acuity 3... 10:15:19 Triage completed. 10:20 Patient Acuity: 2. 10:25:07 Vital Signs: Heart Rate 120!, Resp: 28!, BP: 115/89. 12:05:58 ED LWBS (left without being seen). ED Disposition set to LWBS after Triage ...12:20 Acuity/Destination. Patient Acuity: 1. 12:25 Code Start: code initiated upon pts arrival to room ... 13:31 Deceased Patient's Information: Pronounced by ... 14:29 ED Note Addendum: At approximately 1225 Pt was brought to room 306 after being found
IF CONTINUATION SHEET Page 40 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Continued from page 40P 1702 1702P
unresponsive in ED Lobby. When this RN entered room resuscitation efforts were under way ... ."
An interview on August 27, 2019, with EMP8 revealed that the patient (MR1) had been removed from the Tracking Board after the patient failed to respond when the patient's name was called three different times. EMP8 stated that staff should have gone around the Waiting area and looked for the patient but did not.
Observation of the ED security camera footage revealed the patient (MR1) had their oxygen discontinued, had been removed from the ambulance stretcher into a wheelchair and placed in the Waiting Room by EMS (Emergency Medical Service personnel) and left in front of a Triage Room. That Triage Room was not scheduled to be used that day until after 11:00 AM. EMS personnel was observed speaking with the Pivot Nurse. The patient was not taken over to the Pivot Nurse's desk, nor did the Pivot Nurse get out of the
IF CONTINUATION SHEET Page 41 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Continued from page 41P 1702 1702P
chair, the nurse was not observed to speak with the patient or to examine the patient. The vital signs were taken by the Nursing Assistant. At no time was any staff observed to complete Rounding on MR1 as per their Rounding policy. No movement by the patient was noted from approximately 11:09 AM until approached by staff at 12:20 PM. Staff was observed to have walked past the patient approximately 12 times and staff were observed coming out of the Triage Room approximately seven times. It was observed that some of the staff were within 1-2 feet of the patient (MR1). At 12:20 PM the patient (MR1) was approached by a staff person and taken to a room within the Emergency Department.
The medical record (MR1) did not reveal any documentation by a qualified medical provider prior to 12:25 PM. The patient presented at 9:59, Triage was completed at 10:15, patient sat in the Waiting room of the Emergency Department, was found by staff and taken to room 306 at 12:20 PM. The
IF CONTINUATION SHEET Page 42 of 431DID11State Form
(X2) MULTIPLE CONSTRUCTION:
A. BLDG: __00______________ B. WING: ________________
(X5)COMPLETE
DATE
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC
IDENTIFYING INFORMATION)
(X4) ID PREFIX
TAG
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (POC)
(XI) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
390046
(X3) DATE SURVEY
COMPLETED:
08/30/2019
NAME OF PROVIDER OR SUPPLIER:
YORK HOSPITAL
STATE LICENSE NUMBER: 250301
STREET ADDRESS, CITY, STATE, ZIP CODE:
1001 SOUTH GEORGE STREETYORK, PA 17403
PRINTED: 10/12/2019
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Continued from page 42P 1702 1702P
code was initiated at 12:20 PM.
Interview conducted on August 28, 2019 with EMP 4 confirmed that MR1 did not have documentation of a medical screening examination provided by a qualified medical provider.
IF CONTINUATION SHEET Page 43 of 431DID11State Form
YORK HOSPITALSTATE LICENSE NUMBER: 250301
SURVEY EXIT DATE: 08/30/2019
Certified End Page
THIS IS A CERTIFICATION PAGE
PLEASE DO NOT DETACHTHIS PAGE IS NOW PART OF THIS SURVEY
Rachel L. Levine, MDSecretary of Health
Susan CobleDeputy Secretary for Quality Assurance
I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey
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