pittsburgh hospital out of compliance with patient safety laws

A full state licensure survey of Jefferson Regional Medical Center conducted in October and November, 2010, found that the facility was not in compliance with the Pennsylvania Department of Health’s Rules and Regulations for Hospitals.

According to the report, Jefferson failed to promptly report at least 38 hospital-acquired infections; neglected to document informed consent; failed to document verbal prescription orders; did not verify the identity of patients before surgery; had no plan for ensuring that all patients arriving at the emergency room were assessed; and did not perform required criminal background checks on employees who work with children, among other violations.

The hospital has agreed to implement corrective plans to remedy the safety violations and administrative deficiencies.

“Jefferson Regional Medical Center is fully licensed, and at no point has the license been in jeopardy,” Jefferson spokesperson Candy Williams told the Pittsburgh Tribune-Review in an e-mail.

Hospital’s Negligent Procedures and Recordkeeping Could Threaten Patient Safety

The report, which is posted on the Pennsylvania Department of Health’s website, included a review of hospital policies, patient records, and other data, as well as employee interviews.

According to the report, most of Jefferson’s patient safety violations involved the hospital’s negligence in routinely documenting that important patient safety measures had been followed or that patients’ informed consent had been obtained. The most serious violations occurred in six areas:

  • Pennsylvania’s Medical Care Availability and Reduction of Error Act (MCARE) requires all medical facilities to report all hospital-acquired infections within 24 hours to the CDC’s National Healthcare Safety Network (NHSN), and to notify affected patients within 7 days. Jefferson failed to report 38 hospital-acquired infections occurring in May and September, and in fact had no policy requiring the facility to record the date and time the infections were discovered. Employees told the inspectors they were unaware of the time limits for reporting hospital-acquired infections.
  • The Health Care Services Malpractice Act requires practitioners to obtain a patient’s informed consent before performing any procedure or treatment, except in emergencies. The hospital failed to document the informed consent of four patients for invasive procedures that were performed by a radiological assistant, although the hospital says they did obtain the patients’ consent.
  • Hospital policy limits the use of verbal orders for medication to urgent circumstances and requires them to be clearly documented. The Department of Health found 25 verbal orders in October with no physician signature, date or time.
  • Hospitals are required to establish procedures for ensuring that any ill or injured person entering the emergency room is assessed and either treated, referred or discharged. An interview with a Jefferson employee revealed “We do not have a policy on documentation of patient’s leaving the Emergency Department without being seen.”
  • In order to limit the risk of wrong-patient procedures, hospital policy requires surgical teams to verify and record the identity of all patients prior to surgery. This was not done in any of the nine surgical records the Department of Health reviewed.
  • Pennsylvania’s Child Protective Services Law requires health care facilities to perform criminal background checks on all employees likely to have regular contact with children. The inspection found that the hospital had failed to perform the required background checks on 11 employees.

Proper documentation is the only way to know whether patients’ safety and legal rights are protected at hospitals and health care facilities. A hospital’s negligent failure to follow proper safety and informed consent procedures, and to document having done so, is not just a “paperwork error.” It puts every patient’s safety and health at risk.


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