1.

00

PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0000 INITIAL COMMENT P 0000 0.00

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.

P 0317 P 0317 0.00

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE: (X6) DATE:

State Form 1DID11 IF CONTINUATION SHEET Page 1 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0317 Continued from page 1 P 0317

103.4 (3) FUNCTIONS Completion

The WellSpan Health Corporate Date:
(3) Take all reasonable steps to Patient Safety Officer and the York 10/14/2019
conform to all applicable Federal, Hospital Patient Safety Officer (PSO) Status:
State, and local laws and will amend Policy 602, Adverse APPROVED
regulations. Event Response, to reinforce the Date:
necessity of timely reporting of 10/03/2019
This REGULATION is not met as evidenced by: 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

State Form 1DID11 IF CONTINUATION SHEET Page 2 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0317 Continued from page 2 P 0317

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

State Form 1DID11 IF CONTINUATION SHEET Page 3 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0317 Continued from page 3 P 0317

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.

State Form 1DID11 IF CONTINUATION SHEET Page 4 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0317 Continued from page 4 P 0317

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

State Form 1DID11 IF CONTINUATION SHEET Page 5 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0317 Continued from page 5 P 0317

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

State Form 1DID11 IF CONTINUATION SHEET Page 6 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0317 Continued from page 6 P 0317

not entered until after the facility conducted a Root

Cause Analysis.

P 0351 P 0351 0.00

State Form 1DID11 IF CONTINUATION SHEET Page 7 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 7 P 0351

103.22 (b)(6) IMPLEMENTATION Completion

By 10/7/14 the ED will develop Date:
(6) The patient has the right to standard work to ensure that all 10/18/2019
expect emergency procedures to be patients arriving by ambulance will Status:
implemented without unnecessary be met by the flow coordinator or APPROVED
delay. charge nurse and will be directly Date:
bedded or taken directly to triage. If 10/04/2019
This REGULATION is not met as evidenced by: 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.

State Form 1DID11 IF CONTINUATION SHEET Page 8 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 8 P 0351

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

State Form 1DID11 IF CONTINUATION SHEET Page 9 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 9 P 0351

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.

State Form 1DID11 IF CONTINUATION SHEET Page 10 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 10 P 0351

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.

State Form 1DID11 IF CONTINUATION SHEET Page 11 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 11 P 0351

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

State Form 1DID11 IF CONTINUATION SHEET Page 12 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 12 P 0351

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;

State Form 1DID11 IF CONTINUATION SHEET Page 13 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 13 P 0351

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

State Form 1DID11 IF CONTINUATION SHEET Page 14 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 14 P 0351

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.

State Form 1DID11 IF CONTINUATION SHEET Page 15 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 15 P 0351

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.

State Form 1DID11 IF CONTINUATION SHEET Page 16 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 16 P 0351

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

State Form 1DID11 IF CONTINUATION SHEET Page 17 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 17 P 0351

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

State Form 1DID11 IF CONTINUATION SHEET Page 18 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 18 P 0351

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

State Form 1DID11 IF CONTINUATION SHEET Page 19 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 19 P 0351

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

State Form 1DID11 IF CONTINUATION SHEET Page 20 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0361 Continued from page 20 P 0361

103.22 (b)(16) IMPLEMENTATION Completion

This event has been taken extremely Date:
103.22 seriously at all levels of the 10/14/2019
(16) The patient has the right to organization. The York Hospital and Status:
expect good management techniques to WellSpan Health Boards were made APPROVED
be implemented within the hospital aware. Weekly calls and meetings Date:
considering effective use of the time regarding this matter, status and 10/04/2019
of the patient and to avoid the progress with York Hospital Board
personal discomfort of the patient. Executive Committee have occurred
and will continue until the plan of
This REGULATION is not met as evidenced by: 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

State Form 1DID11 IF CONTINUATION SHEET Page 21 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0361 Continued from page 21 P 0361

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

State Form 1DID11 IF CONTINUATION SHEET Page 22 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0361 Continued from page 22 P 0361

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.

State Form 1DID11 IF CONTINUATION SHEET Page 23 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0361 Continued from page 23 P 0361

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

State Form 1DID11 IF CONTINUATION SHEET Page 24 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0361 Continued from page 24 P 0361

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.

State Form 1DID11 IF CONTINUATION SHEET Page 25 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0361 Continued from page 25 P 0361

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

State Form 1DID11 IF CONTINUATION SHEET Page 26 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0361 Continued from page 26 P 0361

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

State Form 1DID11 IF CONTINUATION SHEET Page 27 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0361 Continued from page 27 P 0361

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

State Form 1DID11 IF CONTINUATION SHEET Page 28 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0361 Continued from page 28 P 0361

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

State Form 1DID11 IF CONTINUATION SHEET Page 29 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1531 Continued from page 29 P 1531

115.33 (a) ENTRIES Completion

The conduct of the nurses involved Date:
115.33 Entries with this incident has been peer 10/14/2019
reviewed and evaluated. Both were Status:
(a) All significant clinical managed in accordance with human APPROVED
information pertaining to a patient resources policies. Date:
shall be incorporated in his medical 10/04/2019
record. Per York Hospital policy Nursing
Documentation Standards, every
This REGULATION is not met as evidenced by: 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.

State Form 1DID11 IF CONTINUATION SHEET Page 30 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1531 Continued from page 30 P 1531

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.

State Form 1DID11 IF CONTINUATION SHEET Page 31 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1531 Continued from page 31 P 1531

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

State Form 1DID11 IF CONTINUATION SHEET Page 32 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1531 Continued from page 32 P 1531

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)

State Form 1DID11 IF CONTINUATION SHEET Page 33 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1531 Continued from page 33 P 1531

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.

State Form 1DID11 IF CONTINUATION SHEET Page 34 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1531 Continued from page 34 P 1531

P 1702 P 1702 0.00

State Form 1DID11 IF CONTINUATION SHEET Page 35 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1702 Continued from page 35 P 1702

117.1 (b) PROVISION OF SERVICES Completion

By 10/7/19 the ED will develop Date:
117.1 standard work to ensure that all 10/14/2019
(b) Where there is an emergency patients arriving by ambulance will Status:
service, it shall provide prompt be met by the flow coordinator or APPROVED
examination or treatment, or both, to charge nurse and will be directly Date:
all persons who come or are brought bedded or taken directly to triage. If, 10/04/2019
into the hospital in need of such after triage evaluation, the patient
treatment, irrespective of ability to has an acuity of ESI 2 or greater,
pay. Such treatment shall be of the they will be placed in a bed for
highest type consistent with the additional evaluation or treatment.
facilities available and with the
standards established in the medical All flow coordinators and charge
community of which the hospital is a nurses will be educated on the new
part. standard work prior to 10/7/19.

This REGULATION is not met as evidenced by: 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,

State Form 1DID11 IF CONTINUATION SHEET Page 36 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1702 Continued from page 36 P 1702

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.

State Form 1DID11 IF CONTINUATION SHEET Page 37 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1702 Continued from page 37 P 1702

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)

State Form 1DID11 IF CONTINUATION SHEET Page 38 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1702 Continued from page 38 P 1702

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.

State Form 1DID11 IF CONTINUATION SHEET Page 39 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1702 Continued from page 39 P 1702

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

State Form 1DID11 IF CONTINUATION SHEET Page 40 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1702 Continued from page 40 P 1702

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

State Form 1DID11 IF CONTINUATION SHEET Page 41 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1702 Continued from page 41 P 1702

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

State Form 1DID11 IF CONTINUATION SHEET Page 42 of 43

 PRINTED: 10/12/2019
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390046
B. WING: ________________ 08/30/2019

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

YORK HOSPITAL 1001 SOUTH GEORGE STREET
YORK, PA 17403
STATE LICENSE NUMBER: 250301

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1702 Continued from page 42 P 1702

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.

State Form 1DID11 IF CONTINUATION SHEET Page 43 of 43

1.00

Certified End Page

YORK HOSPITAL
STATE LICENSE NUMBER: 250301
SURVEY EXIT DATE: 08/30/2019

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

Susan Coble Rachel L. Levine, MD

Deputy Secretary for Quality Assurance Secretary of Health

THIS IS A CERTIFICATION PAGE

PLEASE DO NOT DETACH

THIS PAGE IS NOW PART OF THIS SURVEY