Allegheny General Hospital

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 42809 Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to keep the patient safe by delaying care and not securing the patient who was identified as a high fall risk, who fell from the CT table and sustained a fatal injury (MR1). Findings include: On June 30, 2026, review of the facility “Patient Rights and Responsibilities ... POL-11049960” policy, last approved 1/29/2026, revealed: “ ... You have a right to: ... Receive kind, respectful, safe, quality care delivered by skilled staff. ...” On June 30, 2026, review of facility “Fall Prevention Program ... POL-10436585,” last approved 1/13/2026, revealed: “ ... Administration ASSESSMENT/REASSESSMENT All staff that interact and participate in the treatment of patients are responsible for ensuring a safe environment and minimizing the patient’s risk for falls and risk for injury related to a fall. ... MODERATE Fall Risk Level Interventions... Place fall risk identifiers (arm band) ... Ensure communication regarding fall risk level during transport and transfers ... HIGH Fall Risk Level Interventions .. : Initiate LOW and MODERATE fall risk measures and: Place fall risk patient identifiers (yellow socks, signage) ... “. Review of MR1 was conducted on June 30, 2026, between 10:15 AM and 1:30 PM, on July 1, 2026 between 10:00 AM and 2:00 PM, and on July 8, 2026, between 1:00 PM and 3:00 PM. Review of MR1 revealed that on June 26, 2026 the following occurred: 02:44 AM - The patient presented to the facility’s Emergency Department (ED) with nausea, vomiting and chest pain. 02:52 AM - The Johns Hopkins Fall Risk Assessment was completed and the patient was deemed “High Fall Risk”. 08:57 AM - Orders Placed by EMP8: “ ... Precaution - ... Fall Precautions ...”. 08:59 AM - EMP8 ordered a Coronary CT Angiography (Coronary CTA) for MR1. There was no order for nitroglycerin included with the Coronary CTA order. 11:38 AM - The patient (MR1) checked in to CT Scanning for the Coronary CTA test. During interview with EMP5 on June 30, 2026, at 10:30 AM, EMP5 explained that while in CT Scanning, the patient was moved to the CT scanner table where she remained on the table, unsecured. The test was not completed at this time because the patient did not have an order for nitroglycerin, which was needed to complete this test 12:13 PM - EMP9 ordered “ ... nitroglycerin (NITROSTAT) 0.4 mg SL tablet ... Frequency: ... 1 occurrence ...”. This medication order was acknowledged by the registered nurse at 12:23 PM and verified by the pharmacist at 12:27 PM. MR1 fell from the CT table. At 12:31 PM, a stat CT of the head was initiated and revealed: “Acute left-sided subdural hemorrhage measuring up to 1.1 cm. Additional subdural hemorrhage along the falx and left tentorial leaflet. Additional small right-sided subdural hemorrhage. No midline shift”. 2:54 PM - Due to a significant deterioration of health, the patient was made comfort measures only and ceased to breath at 3:00 PM. During interview with EMP1 on July 8, 2026, at 3:00 PM, EMP1 confirmed that the patient was high fall risk and did not have a fall risk bracelet or yellow socks. During interview with EMP5 on June 30, 2026, at 10:30 AM , EMP5 confirmed that a safety strap was not used to secure MR1 while waiting for the Coronary CTA scan. During interview with EMP1 on June 30, 2026, at 1:30 PM, EMP1 confirmed that the patient’s Coronary CTA was delayed while the patient waited for the nitroglycerin and during this time, the patient fell from the CT table.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 45574 Based on a review of facility documents, medical records (MR) and employee interview(EMP), the facility staff failed to adhere to the hospital policies and procedures regarding telemetry in five of five medical records (MR2, MR3, MR4, MR5, and MR6) Findings include: On June 24, 2025, a review of POL-7657421, Bedside and Telemetry Monitoring (Last Approved: 6/2/2025; Last Revised: 6/2/2025) was completed and revealed the following: C. Monitored Units: 1. On arrival, initiation of monitoring, change in care giver, and any time patient comes on/off monitor, (i.e. transport/ bathing) the monitor tech will verify patient name, room number, pack number, and order for monitoring. If there is not an order contact the nurse to obtain an order from the provider. The monitor tech will check daily for an order for continuous cardiac monitoring and notify the nurse if an order is needed. 2. The nurse will take the telemetry pack to the patient, apply the electrodes and the monitor pack. The Nurse will call the monitor tech to make sure the rhythm is visualized. The RN will physically look at pack and verify box number with monitor tech. The monitor tech will document on log sheet and nurse will document box number in EPIC. a. During each assigned handoff or when the patient is off the floor for procedures/testing, the RN shall validate the telemetry box number matches the monitor tech log. Confirmation shall be documented within EPIC under the complex cardiac assessment flow sheet by the RN. 3. A monitor tech will be assigned to watch the central monitors on each shift. A registered nurse may rotate to this position. The staff member assigned to monitor telemetry may not leave the monitors unattended at any time. Coverage will be provided for breaks and lunch... 5. For each patient the monitor tech will document in Epic under the complex cardiac assessment time, lead, heart rate, PR interval, QRS duration, QT interval and strip interpretation every 12 hours (0730 and 1930) ...6. The bedside nurse: a. Will analyze and review the interpretation and measurements done by the monitor tech and document. b. Will document the rhythm and rate with vital signs. c. Will document if there are cardiac symptoms d. The nurse will also document if the rhythm was reviewed with the monitor tech. this is located under the complex cardiac assessment “ EKG strip reviewed “ and choose “ with monitor tech. “ On June 24, 2025, a review of open medical records on Unit 5C was completed and revealed the following: On May 21, 2025, MR2 was transferred from the ICU to Unit 5C and ordered telemetry monitoring. There was no documentation, upon transfer, at 01:41, of the telemetry box number. On May 23, 2025, at 10:00 PM, the monitor tech failed to document PR interval, QRS duration, and QT interval, per facility policy. On May 24, 2025, there was no rhythm strip located in MR2 for the shift commencing at 1930. On June 22, 2025, MR3s telemetry was discontinued and re-ordered at 1603 on June 23, 2025. On June 23, 2025, at 1834 and 1931, it is noted that the telemetry box number was not documented with the reapplication of the telemetry monitor. On June 24, 2025, at 0900, the telemetry box number was entered into MR3, 13.5 hours after re-application. On June 23, 2025, MR4was transferred from the intensive care unit to Unit 5C. Telemetry was ordered. On June 23, 2025, at 1929, the telemetry pack number was not documented, per policy. However, it was documented that MR4 was on a bedside monitor. On June 24, 2025, at 0730, neither the lead nor telemetry pack number was documented. MR4 was documented to be on a bedside monitor, at this time. On June 24, 2025, at approximately 12:15 PM, EMP3 was asked if Unit 5C had beside monitoring capability. EMP3 stated that the unit did not have bedside capability- only telemetry. On June 14, 2025, MR5, admitted for a NSTEMI, arrived to Unit 5C at 1311 with an order for telemetry. At 1327, the monitor tech and the RN failed to document the telemetry pack number. On June 14, 2025, at 2057, the monitor tech failed to document the telemetry pack number. The RN documented at 1342, 2015, and 2339 and failed to document the telemetry pack number per hospital policy. The telemetry pack number was not documented in the medical record until June 18, 2025 at 0155, approximately 3.5 days after admission. Lead of the telemetry tracing for MR5 was not documented by the monitor tech on June 15, 2025 at 0729 and 2101; June 16, 2025, at 0730 and 2316; June 17, 2025, at 0729 and 2000; and June 18, 2025 at 0730 and 2342. On June 21, 2025, MR6 was admitted to Unit 5C with a diagnosis of bradycardia and ordered telemetry. Lead(s) of the telemetry tracing for MR6 was/were not documented by the monitor tech on June 22, 2025 at 0729 and 2134; June 23, 2025, at 0732 and 1932; and June 24, 2025, at 0730. On June 24, 2025, the above findings were confirmed with EMP2 between 11:30 AM and 1:30 PM.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 42809 Based on review of facility policies, medical records (MR), and interview with staff (EMP), it was determined the medical staff failed to follow its bylaws by failing to abide by facility policies for obtaining informed consent and performing timeout prior to bedside procedures for two of twenty medical records reviewed (MR1, MR2). Findings include: Review of facility policy entitled “Universal Protocol: Pre-procedure Verification, Site Marking, and Time-Out ... POL-6953392”, last revised 10/31/2023, revealed: “ ... Allegheny Health Network will protect patient safety by correctly identifying the patient, the procedure, and the site prior to operative and invasive procedures, including procedures done for both diagnostic and treatment-related purposes. This policy applies not only to procedures being performed in the operating room but to other procedural rooms or at the beside. ... “. Review of facility policy “General and Informed Consent ... POL-6241648 ...”, last approved 5/19/2023, revealed: “ ... Except in emergency situations, Informed Consent must be obtained from the patient or appropriate Legally Authorized Representative prior to the performance/administration of surgery; anesthesia; radiation; ... insertion of a surgical device or appliance ... It is the responsibility of the Physician who will perform, order or supervise the treatment or procedure to obtain the patient’s Informed Consent. ...”. Review of MR1 revealed that on February 13, 2024 at 8:44 AM, the patient signed an informed consent for a right side thoracentesis. On February 13, 2024, at 9:34 AM, a left side thoracentesis was performed. Further review of MR1 revealed no time out was performed prior to the procedure. Review of MR2 revealed the patient signed a informed consent on February 25, 2024 at 10:15 AM, for a “TALC Pleurodesis”. On February 25, 2024 at 12:35 PM, a “Pleurodesis” was performed on the patient of MR2, but the site was not marked during the pre-procedure time out per facility policy. Further review of MR2 revealed the patient consented to and underwent a left sided thoracentesis on March 1, 2024, at 4:44 PM. Further review of MR2 revealed the site was not marked during pre-procedure time out per facility policy. The above was confirmed with EMP1 during medical records review on March 11, 2024, between approximately 11:00 AM and 1:00 PM.”