Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure patient vital signs were taken when assessed in the Triage area of the Emergency Department (ED) for nine of 10 medical records reviewed (MR1. MR2, MR3, MR4, MR5, MR6, MR7, MR8 and MR9). Findings include: Review on May 16, 2019, of the facility's "Acute Stroke Practice Guidelines for the Emergency Department" policy, no review date, revealed "Purpose Lehigh Valley Hospital - Pocono (LVH-P) has adopted these practice guidelines in order to provide an evidence-based approach to treating patients who present with signs and symptoms consistent with acute stroke. Although these guidelines assist in guiding care, responsibility to determine appropriate care for each individual remains with the provider themselves. ... Guidelines 1. Patient's chief complaint will be documented. Stroke symptoms include: sudden onset of numbness or weakness of the face, arm or leg, especially on one side of the body; confusion, trouble speaking or understanding speech; trouble seeing in one to both eyes; trouble walking, dizziness, or loss of balance or coordination; severe headache with no known cause or "worst headache of my life". ... 3. For patients with the last known well/last normal 24 hours or less, a stroke alert will be called ..." Review on May 16, 2019, of the facility's "Standard of Care: Emergency Department" policy, no review date, revealed "... Guidelines 1. Triage & Assessment a. All patients presenting to the Emergency Department shall receive a screening exam to determine if they have an emergency medical condition. ...b. The ESI - Emergency Severity Index tool will be used to triage all patients in the emergency department. ...iv. Level - 3 (Non-urgent) the patient presents with a condition that could progress to a serious problem requiring emergency interventions. The vital signs of a level three patient may or may not be outside normal limits (danger zone) and presenting condition is anticipated to require the utilization to two or more resources. v. Level 4 - (Non-urgent) the patient presents and has a low potential for deterioration or complication. One resource is expected to treat this patient. ... 18. Please note a complete set of vital signs are obtained on all patients on arrival and within one hour of discharge. ..." Review of MR1 revealed this patient presented on April 29, 2019, with a chief complaint of left side numbness for three days and was triaged with an ESI level 3. There was no documentation ED staff took MR1's vital signs as per facility policy. Review of MR2 revealed this patient presented on April 29, 2019, with a chief complaint of dizziness and was triaged with an ESI level 3. There was no documentation ED staff took MR2's vital signs as per facility policy. Review of MR3 revealed this patient presented on April 29, 2019, with a chief complaint of dizziness and was triaged with an ESI level 3. There was no documentation ED staff took MR3's vital signs as per facility policy. Review of MR4 revealed this patient presented on April 29, 2019, with a chief complaint of left upper abdomen pain and right arm swelling and was triaged with an ESI level 3. There was no documentation ED staff took MR4's vital signs as per facility policy. Review of MR5 revealed this patient presented on April 29, 2019, with a chief complaint of right-side flank pain and was triaged with an ESI level 3. There was no documentation ED staff took MR5's vital signs as per facility policy. Review of MR6 revealed this patient presented on April 29, 2019, with a chief complaint of cough and short of breath and was triaged with an ESI level 3. There was no documentation ED staff took MR6's vital signs as per facility policy. Review of MR7 revealed this patient presented on April 29, 2019, with a chief complaint of a laceration to the head and was triaged with an ESI level 4. There was no documentation ED staff took MR7's vital signs as per facility policy. Review of MR8 revealed this patient presented on April 29, 2019, with a chief complaint of a sore throat and congestion and was triaged with an ESI level 4. There was no documentation ED staff took MR8's vital signs as per facility policy. Review of MR9 revealed this patient presented on April 29, 2019, with a chief complaint of lower back pain and was triaged with an ESI level 4. There was no documentation ED staff took MR9's vital signs as per facility policy. Interview with EMP1, EMP2, EMP3 and EMP4 on May 16, 2019, at approximately 11:00 AM confirmed ED staff did not document vital signs on patients assessed in the Triage area of the ED for MR1. MR2, MR3, MR4, MR5, MR6, MR7, MR8 and MR9. EMP3 revealed it is expected that patient vital signs be taken and documented when a patient is triaged in the ED.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a patient with suicidal thoughts and actions was not provided utensils while a patient in the Emergency Department for one of one applicable medical record reviewed (MR1). Findings include: Review on May 9, 2017, of the facility's "Effective Security Patrolling" policy, no review date, revealed "Purpose the primary responsibility of Pocono Health System Security Department is to maintain a safe and secure environment in which to administer patient care. Part of the Pocono Health System's security system includes regular foot patrols by security officers on prevention and deterrence, discovery and apprehension of criminal subjects and identification of potential safety hazards. ..." Review on May 9, 2017, of the facility's "Limited Authority / Use of Force / Search and Seizure" policy, effective July 19, 2016, revealed "1. Purpose the purpose of this policy is to describe a Security Officer's authority to act in situations where detainment, use of force, or search and seizure may be necessary for protecting persons and property under the care and responsibility of the Pocono Medical Center. 2. Procedure a Security Officer's legal authority is delineated in three segments as follows; A. Detainment B. Use of Force C. Search and Seizure ..." Review on February 1, 2017, of the Manager, Safety and Security, job description, last reviewed November 10, 2015, revealed, "Job Summary: Responsible for developing, implementing and monitoring systems, programs and policies designed to promote a safe and secure environment in which to administer patient care. Coordinates activities of the Security Department to provide protective services for patients, visitors, employees and corporate assets. Major Tasks, Duties, and Responsibilities: Is responsible for the development of a comprehensive physical Security program and directs operations of Security Services Department which is responsible for maintaining a safe environment for our staff, patients and visitors - 24/7. ... ." Review of MR1 on May 9, 2017, revealed the patient was admitted to the Emergency Department (ED) on April 4, 2017, for evaluation and treatment of an intentional overdose. Nursing documentation revealed on April 6, 2017, at 8:32 AM, the patient received a Safe Tray for breakfast. At 13:52, the patient ate French fries and a peanut butter and jelly sandwich. At 15:00 EMP4 made rice for the patient from the kitchen. Interview with EMP4 on May 9, 2017, at approximately 9:45 AM confirmed EMP4 provided MR1 with rice. EMP4 confirmed they also provided MR1 with a spoon to eat the rice. EMP4 revealed intervening on behalf of the patient and providing food and utensils to a mental health patient promoted a relationship and trust with the patient. EMP4 revealed they were a Security Guard and was not trained to provide psychiatric care or interventions to a patient with suicidal thoughts or actions. Interview with EMP5 on May 9, 2017, at approximately 1:30 PM revealed all patients with suicidal thoughts and actions were provided a Safe Tray. The Safe Try included the paper trays, Styrofoam cups, finger foods, and no utensils. EMP5 revealed there was no facility policy, procedure or guideline for facility staff to follow regarding a Safe Tray. Interview with EMP1, EMP2, EMP3 and EMP4 on May 9, 2017, at approximately 10:00 AM confirmed EMP4 provided MR1 with rice and a spoon; MR1 was in the ED due to a suicidal attempt; and MR1 was to have only paper trays, Styrofoam cups, finger foods and no utensils. Continuing deficiency cited February 1, 2017

Based on a review of facility documents, medical records (MR) and staff interview (EMP), it was determined that Pocono Medical Center failed to ensure acceptable standards of Emergency Services were provided to meet the emergency care needs of a patient presenting with alcohol abuse and intoxication, opiate drug use, depression and suicidal thoughts for one of 12 applicable medical record reviewed (MR1). Findings include: Review on February 1, 2017, of facility Assessment and Intervention of the Suicidal Risk Patient policy, last approved April 10, 2015, revealed, "Purpose: Pocono Medical Center clinical staff will proactively screen patients being treated for emotional or behavioral in disorders and for the risk of suicide at initial contact. Patients identified to be at risk for suicide will be further assessed. 1. To identify patients at risk for suicide in the hospital setting. 2. To meet the patient's immediate safety and assure the most appropriate setting for treatment. ... ." Review on February 1, 2017, of facility Patient Elopement policy, effective July 8, 2011, revealed, "1. Purpose: a. It is the Policy of PMC to implement reasonable guidelines to prevent and report patient elopement. As provided in Pennsylvania law, under certain circumstances patients who have been deemed a danger to themselves and/or others can be detained involuntarily. These patients may present under one or more of the following condition, but are not limited to the following: i. Intoxicated patients ii. Patients medicated with drugs that may impair functioning iii Head injured patient or those with altered level of cognition for whatever reason iv. Psychiatric patients. 2. Guidelines a. Procedure/Responsibility/Action i. When a patient is deemed clinically to be a danger to him/her, and/or others, measures will be taken to detain that patient while care and/or evaluation are being provided. ii. A specific approach to preventing elopement is based on the patient's individual needs. iii. Measures such as the following should be considered and/or implemented by the nursing/crisis/medical staff to encourage patient compliance: 1. Providing verbal explanation, teaching or coaching on reasons to stay for treatment. 2. Placing the patient in a room directly in from of or near the nurses station. 3. Requesting the assistance of security to monitor the patient's activity. 4. Complete Crisis evaluation as soon as possible. 5. Physical controls such as locked seclusion room and/or physical restraints. The least restrictive measure should be utilized. ... ." Review on February 1, 2017, of facility Smoke Free Campus policy, no review date, revealed, "Purpose: Pocono Health System is dedicated to improving the health of our patients and employees. We also believe in providing an environment which encourages a healthy lifestyle for our employees, medical staff, volunteers, and visitors. Allowing the use of tobacco products on the Health System campus does not portray our health System as a leader in the community, and does not promote a healthy environment. ... ." Review on February 1, 2017, of the Manager, Safety and Security, job description, last reviewed November 10, 2015, revealed, "Job Summary: Responsible for developing, implementing and monitoring systems, programs and policies designed to promote a safe and secure environment in which to administer patient care. Coordinates activities of the Security Department to provide protective services for patients, visitors, employees and corporate assets. Major Tasks, duties, and Responsibilities: Is responsible for the development of a comprehensive physical Security program and directs operations of Security Services Department which is responsible for maintaining a safe environment for our staff, patients and visitors - 24/7. ... ." Review of MR1 on February 1, 2017, revealed the facility admitted this patient to their Emergency Department (ED) on January 1, 2017, at 8:41 AM with alcohol abuse and intoxication for three days, opiate drug use, depression and suicidal thoughts. Review of MR1 on February 1, 2017, revealed the following: At 9:00 AM, MR1 was placed on suicidal prevention precautions which included: 1:1 observation for safety and changed into hospital scrubs. At 9:07 AM the ED physician ordered nursing staff to apply restraints to MR1's both right and left arms and legs for combativeness and unable to follow commands. Interview with EMP1 and EMP2 on February 1, 2017, at approximately 10:20 AM confirmed MR1 was admitted to the facility ED with alcohol abuse and intoxication for three days, opiate drug use, depression and suicidal thoughts; MR1 was placed on suicidal prevention precautions which included: 1:1 observation for safety and changed into hospital scrubs; and the ED physician ordered nursing staff to apply restraints to MR1's both right and left arms and legs for combativeness and unable to follow commands. Review on February 1, 2017, of facility PHS Safety and Security Activity Log, dated January 11, 2017, revealed EMP7 was called to the ED at 9:30 AM for MR1 who was intoxicated and threatening to leave. EMP7 escorted MR1 out of the building at 9:30 AM for a cigarette. Interview with EMP1, EMP2 and EMP7 on February 1, 2017, at approximately 11:50 AM confirmed EMP7 was called to the ED at 9:30 AM for MR1 who was intoxicated and threatening to leave, that EMP7 escorted MR1 out of the building at 9:30 AM for a cigarette. Further interview with EMP7 revealed this employee escorted MR1 to the bus stop in front of the hospital which is on a busy two lane road, for a cigarette. EMP7 revealed this employee is a Security Guard and is not trained to provide medical care or psychiatric care should a patient require this type of care. Review on February 1, 2017, of MR1 revealed physician documentation dated January 11, 2017, at 10:32 AM instructing ED Nursing Staff to administer the following medications: Ativan (medication used to treat anxiety) 2 milligrams (mg) Intramuscular (IM) at 10:11; Benadryl (an antihistamine and anti-anxiety medication) 50 mg IM and Geodon (a medication used to treat manic depression) 10 mg IM. Interview with EMP1 and EMP2 on February 1, 2017, at approximately 12:00 PM confirmed the physician documentation instructing ED nursing staff to administer Ativan 2 mg IM; Benadryl 50 mg IM and Geodon 10 mg IM. Interview with CF1 and CF2 on February 1, 2107, at approximately 1:00 PM revealed any patient admitted to the ED with alcohol abuse and intoxication, opiate drug use, depression and suicidal thoughts would be placed on 1:1 observation with a sitter. CF1 and CF2 confirmed it is not facility practice to allow any patient to be escorted from the ED to the bus stop area on a busy two lane road for a cigarette due to the potential for stepping into traffic or eloping.

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure the outpatient services to which the patient was referred was documented in the medical record and failed to ensure a list of area shelters was provided to one of one medical record reviewed (MR1) when discharged from the facility's Emergency Department (ED). Findings include: Review on July 9, 0215, of the facility's "Crisis Intervention Services in the Emergency Department" policy, last reviewed April 18, 2015, revealed "Purpose It is the policy of Pocono Health System to provide a Behavioral Health Crisis Intervention Service. This service will be provided during the hours of 0700-2300 on site and 2300-0700 on call coverage Monday through Friday. Weekend and holiday coverage is 1100-2300 on site and both 0700-1100 and 2300-0700 on call. The Crisis Intervention Specialist (CIS) will respond to ED physician orders for a Crisis evaluation and report findings to the ED physician and nurse and the psychiatrist on-call, as appropriate. Human Service Agencies will be made to provide an efficient, effective and respectful response to the needs of behavioral health patients and their families. Scope Crisis Intervention Specialist Guidelines 1. Crisis Intervention Specialist a. Conduct on-site consultation when indicated by ER physician. Complete detailed Suicide Risk Assessment. b. Complete CIS Consultation/Intake Form, using collateral information if patient unable to give coherent medical/psychiatric history. c. Contact psychiatrist on call to relay pertinent information Re: diagnostic impression and treatment recommendations. d. Make recommendations to ER physician. e. Document findings and recommended disposition. ... g. If out-patient or partial hospitalization services are indicated, make referral to appropriate agency." Review on July 9, 2015, of MR2 revealed a family member completed a Mental Health Procedures Act of 1976 Section 302 paperwork. MR2 allegedly threatened to kill a family member and to burn the house down. Review on July 9, 2015, of MR2 revealed psychiatrist documentation. The patient was evaluated by CF2. CF2 determined the patient's behavior did not support a mental health crisis. CF2 denied MR2's 302 commitment. Further review revealed CF2 documented the patient was not allowed to return to home. Review on July 9, 2015, of MR2 revealed Crisis Intervention Specialist (CIS) documentation. EMP4 was aware of MR2's 302 denial, and the patient was not allowed to return to home. Further review revealed EMP4 documented MR2 was discharged from the ED with referral to outpatient services. There was no documentation in MR2 indicating what outpatient services were offered to the patient or that a list of area shelters was provided to the patient. Review on July 9, 2015, of MR2 revealed nursing documentation. The patient was discharged to home. Interview with EMP1 and EMP5 on July 9, 2015, at approximately 1:15 PM confirmed MR2's family member completed a Mental Health Procedures Act of 1976 Section 302 paperwork for allegedly threatening to kill a family member and to burn the house down; CF2 documented MR2's behavior did not support a mental health crisis and denied the 302 commitment. Further interview with EMP5 confirmed MR2 was discharged from the ED with referral to outpatient services and was not allowed to return to home. EMP5 confirmed there was no documentation indicating what outpatient services were offered or that a list of area shelters was provided to the patient.

Based on review of the American Heart Association document, facility policy, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure reassessment of an emergency room patient was completed within two hours for a Level 3 patient for one of 18 medical records reviewed (MR1). Findings include: Review on February 24, 2015 of the facility's policy "Standards of Care: Emergency Department," last revised July 23, 2014, revealed "Purpose Pocono Medical Center Emergency Department adopts the standards of care of the Emergency Nurses Association and outlines below aspects that are specific to the provision of emergency services in PMC [Pocono Medical Center] Emergency Department. Scope Emergency Department Registered Nurse ... Guidelines ... 4. Assessment of patients: a. Assessment can be divided into primary and secondary assessment. Assessments shall be initial and ongoing. ... 17. Reassessment of Patients: a. Patients that are in the treatment areas or triage area will be reassessed based on the patient level. .. e. A guideline for patients to be assessed and reassessed as follows: ... iii. Level 3 patients - reassessed every 2 hours or sooner if warranted by the patient's condition. VS [vital signs] every 2 hours or sooner if indicated." Review of the American Heart Association document "Understanding Blood Pressure Readings," revealed the normal blood pressure category as systolic (upper number) less than 120, and diastolic (lower number) less than 80. Review of MR1 revealed the patient presented on [DATE], at 13:16 with the complaint of mid upper back pain. Triage was completed at 13:22. The patient's blood pressure was 173/96. Level 3 designation was assigned to MR1. The next documented blood pressure was 160/89 at 19:40. The patient's blood pressure on discharge at 22:30 was 178/96. Interview with EMP1 on February 24, 2015, at approximately 11:00 confirmed the documentation of an elevated blood pressure at 13:22. EMP1 confirmed the next documented blood pressure was at 19:40 and was 160/89. EMP1 confirmed the facility policy for reassessment and vital signs was not followed.