This report is the result of an unannounced onsite complaint investigation (CHL14C9BDH) completed on August 22, 2014, at Milton S Hershey Medical Center. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.
Plan of Correction:
103.22 (b)(7) LICENSURE
Name - Component - 00
(7) The patient has the right to
good quality care and high
professional standards that are
continually maintained and reviewed.
Based on a review of Patient Rights, medical record (MR) and interviews with staff (EMP), it was determined that Milton S Hershey Medical Center failed to provide good quality care and high professional standards by giving conflicting information for one of ten medical record reviewed (MR1).
A review of the facility Patient Rights revealed a patient has the Right to "Receive efficient and quality care with high professional standards that are continually maintained and reviewed."
A review on August 19, 2014, of MR1 revealed the patient sustained a back injury on August 1, 2014, and required the application of a back brace.
An interview conducted on August 19, 2014, at 10:45 AM with EMP8 revealed the patient was instructed to place the back piece on top of the front piece.
An interview conducted on August 21, 2014, at 8:10 AM with EMP9 revealed that this brace was custom made for the "Front to go over the back." EMP9 stated the entire plastic brace is padded except for a couple inch section along the edge of the front piece. This allows for the front edge to go on top of the back piece which is completely padded.
Plan of Correction:
1. On 8/25/14, the Penn State Hershey Medical Center (PSHMC) Physical Therapy (PT) Supervisor and on 8/26/14 the Occupational Therapy (OT) Supervisor educated the staff members directly involved with this patient as to the correct application of the custom made back brace. Questions by the staff were answered and staff indicated that they understood that the design of the brace was for the “Front to go over the back”.
2. By 9/15/14, all PSHMC Physical Therapy and Occupational Therapy clinical staff who are assigned to acute care will be trained on correct application of back braces through attendance at an in-service presented by PSHMC’s Prosthetics and Orthotics supplier, or by review of written in-service materials.
3. Effective 8/29/14, the Therapy Services Manager will ensure that all newly hired Physical Therapy and Occupational Therapy staff who are assigned to acute care will be educated on the correct application of the various back braces utilized in the hospital within 90 days of their hire date. This process will be evidenced by a documented orientation competency. No new staff will independently apply a back brace until their competence has been demonstrated per department protocol.
4. Beginning 9/15/14, the Physical Therapy Supervisor, Occupational Therapy Supervisor or their designee will randomly observe the initial back brace applications by PT/OT staff to determine 1) if the back brace was applied correctly 2) to evaluate the accuracy of PT/OT staff patient instructions concerning the application of the brace and 3) to ask the patient if they have received any conflicting information regarding the correct application of the brace. Any non-compliance with the correct application of the back brace or any instances of the patient receiving conflicting information regarding the correct application of the back brace will be reported to the staff member’s supervisor who will take corrective action as needed to ensure compliance is maintained. Observations will occur for a minimum of 2 months and continue until compliance is achieved.