Excela Health Latrobe Hospital

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 50900 Based on a review of facility documents, medical record review (MR), and staff interview (EMP), it was determined that the facility failed to maintain monitoring of the restrained patient as required by facility policy for one out of seven medical records reviewed (MR9). Findings include: Review on July 14, 2026, of “Policy and Procedure for Patient Restraint and Seclusion”, last approved 3/2026, revealed the following for violent / self-destructive restraints, “... Assessment / Continual Monitoring / Patient Care Requirements: 1. A qualified direct patient care provider will continually monitor all patients in restraints or seclusion. ... 3. An assessment is completed by a registered nurse at the initiation of restraints and patients are assessed every 15 minutes therafter by a registered nurse or other specialty trained staff. ...” Review of MR9 conducted on July 14, 2026, at 10:00 AM, revealed an order for violent restraints placed on June 7, 2026, at 11:25 PM. The order was discontinued on June 8, 2026, at 3:37 AM. During this time frame, only one 15-minute restraint assessment was entered by the nurse, on June 8, at 1:00 AM. This reveals 20 out of 21 restraint assessments were not completed as required by facility policy. On July 14, 2026, at approximately 11:15 AM, EMP8 confirmed that MR9 did not contain evidence of violent restraint assessments completed per facility policy.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 46390 Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the facility failed to supervise the patient’s care to ensure the patient’s cardiac status was being monitored at all times and failed to follow the cardiac standards of care and failed to ensure that a registered nurse (RN) supervised the assigned care provided by the patient safety associate for one of 10 medical records reviewed (MR1). Findings include: Review of facility policy “Cardiac Monitoring Standard of Care - EXC”, last approved March 2026, revealed: “A physician’s order is required for cardiac monitoring. Once initiated, cardiac monitoring is continuous until a physician’s order to discontinue is obtained.” Review of facility policy, “Patient Sitter Policy”, last approved September 2025, revealed: “It is the policy of the health system to utilize patient sitters in accordance with established standards of minimize the safety risk to the patient or another individual. This policy applies to all employees or Contractor employees working in a sitter position or capacity within the health system. ... Patient sitters must always provide continuous observation (continuous view of patient(s)) to the assigned patient(s).” Review of facility document, “Patient Safety Associate”, last updated August 2022, revealed: “The Patient Safety Associate provides a safe environment for a patient who requires supervision, companionship and/or diversion. ... Performs duties for an irrational patient as directed by the nurse responsible for the care of that patient. Always sits in patient’s room with an unobstructed view of the patient. ... Provides constant observation and documents observations on safety report sheet. Continuous observation is defined as: continuous visual watch of a patient, within-arms length while patient is awake, always requiring a dedicated staff member in attendance.” Review of MR1 on July 14, 2026, revealed that an order for continuous telemetry (cardiac rhythm monitoring) was placed by EMP11 on June 27, 2026, at 8:20 PM, due to the patients “altered mental status”. This order remained active until June 29, 2026, at 6:08 AM. On June 28, 2026, between 9:10 AM and 1:41 PM, no telemetry monitoring was completed for MR1. This reveals an approximate 4.5-hour lapse in electrocardiogram monitoring, which does not meet the requirement of ‘continuous’, per facility policy and the physician order. On June 28, 2026, at 2:28 PM and June 29, 2026, at 6:08 AM, no telemetry monitoring was completed for MR1. This reveals an approximate 15-hour lapse in electrocardiogram monitoring, which does not meet the requirement of ‘continuous’, per facility policy and the physician order. On July 14, 2026, at 11:30 AM, EMP4 confirmed that the patient of MR1 did not receive telemetry monitoring as ordered by the physician and as required by facility policy. Review of MR1 conducted on July 14, 2026, revealed an order for a continuous sitter (observation) placed by EMP11 on June 28, 2026, at 8:53 PM, following communication by nursing staff that the patient was repeatedly attempting to get out of bed, attempting to kick staff, and remove medical equipment. This order remained active throughout the evening until June 29, 2026, at approximately 6:08 AM. On July 13, 2026, during staff interview at 10:45 AM, EMP4 revealed that on June 29, 2026, between approximately 6:00 and 6:08 AM, MR1 did not have a staff member present in the room, despite an active order for a continuous sitter (patient safety associate). When EMP13 returned to the patient’s room at 6:08 AM, MR1 was discovered to be unresponsive, without a pulse, and not breathing. On July 14, 2026, at 11:30 AM, EMP4 confirmed that staff caring for MR1 did not follow the facility’s Cardiac Monitoring Standard of Care-EXC Policy by not maintaining continuous telemetry, and not adhering to the Patient Sitter Policy’s definition of continuous observation.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 46390 Based on a review of facility documentation and video and medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure that hospital policies and procedures were adhered to in the Emergency Department for ten of 20 medical records reviewed (MR1, MR2, MR4, MR5, MR8, MR9, MR10, MR13, MR14, and MR18). Findings include: On April 22, 2024, a review of the facility policy Patient Assessment in the Emergency Department revealed, “Policy Detail: 12. Standing protocols for treatment after initial assessment can be found in the Emergency Department Protocol Book. 13. Reassessment should be documented hourly or more frequently depending upon specific patient condition, or as ordered by physician. Reassessment is also indicated to document the effects of medication or treatment or at any time patient condition changes. The RN is responsible. for notifying the ED physician of changes in patient status. Vital signs should be rechecked as noted: ... Non urgent classified patients shall have vital signs every 2 hours and prn (as needed).” On April 22, 2024, a review of the facility policy Positive Identification of Hospital Patients (Last Reviewed: 03/2023) revealed. “Outpatient; 2. Emergency Department- Upon entry to the Emergency Department, the initial contact ER staff member obtains the patients name, date of birth, sex, social security number and chief complaint. Using this information, the patient is entered into the Emergency Department Tracking Board. The bracelet is applied per the above stated policy ...10. An additional bracelet(s) will be applied to the patient’s extremity in the same location as the identification bracelet for the following reasons. These bracelets are color coded to enhance communication among caregivers: “Yellow- Fall Alert ...”. On April 22, 2024, a review of the facility policy Fall/Safety Alert Protocol (Last Reviewed: 11/2022) revealed, “II. Policy Statement: A fall-injury risk assessment will be conducted on admission, daily, and after a fall occurrence in order to determine fall-injury risk on all acutely ill or injured adult patients receiving inpatient or observation services ... Patients admitted to the Emergency Department, Behavioral Medicine and Perinatal areas would be exempt.” On April 22, 2024, a review of the facility policy revealed that the Code Amber activation will occur for patients with known cognitive impairment. Follow up phone calls to next of kin/emergency contact and patient will be attempted to determine the status of the patient’s safety as well as to encourage an emergency evaluation as soon as possible.” On April 22, 2024, a review of MR1 revealed the patient was an 83 year old female who was brought to the Emergency Department via ambulance from a skilled nursing center where the patient resides on a locked Dementia unit. The record further revealed a Pre-Arrival Form, dated April 16, 2024, at 13:51 with the chief complaint of “Fall”. The Registration time note in the record was 13:59. The initial Triage revealed MR1 had a head contusion after the patient tripped and fell. The initial assessment indicated the patient was alert and oriented with a Glasgow Coma scale: 14, Eye opening- spontaneous, Best verbal response-confused, Best motor response-obeys simple commands, Emergency Severity Index (ESI) 4. No Known Allergies. MR1 was triaged at 14:40, 40 minutes after arrival. Neuro Checks, Glasgow Coma Scale and Vital Signs were ordered at 1451 to be done at 1451 and repeated every hour per the facility Closed Head Injury Protocol. No fall risk assessment was completed and the patient did not receive a yellow armband to be identified as a fall risk. CT of the Head Result at 15:38. Impression: Negative for fracture or intracranial hemorrhage. Volume loss and chronic small vessel ischemic change. 18:30, 19:10, 19:25 patient was taken to the waiting room. On April 22, 2024, review of video revealed a brief conversation between emergency medical services (EMS) and EMP11. At 14:04, it is noted that EMS moves the MR1 from the stretcher to a wheelchair. MR1 is placed, into the Emergency Department waiting room by EMS at 14:09. Further review of MR1 revealed a lack of reassessment, repeat Neuro Checks, Glasgow Coma Scale, fall risk assessment, cognitive assessment, neuro assessment and Vital Signs for MR1. Additionally, on April 16, 2024, the patient had not yet seen by a provider at 17:04. At 18:30, 19:10, 19:25, on April 16, 2024, staff attempted to call MR1 for reassessment, MR1 was no longer in the waiting room. Review of video revealed that MR1 left the emergency department waiting room at 17:05 with an unknown person and left the facility’s premises in a black sports utility vehicle. A review of MR2 on April 22, 2024, revealed a 34 year old who presented to the Emergency Department on January 29, 2024, with a diagnosis of foot pain and swelling. There was no documentation of a nursing reassessment on January 29, 2024, from 20:52 until January 29, 2024, at 22:57 when the patient eloped. A review of MR4 on April 22, 2024, revealed a 14 year old who presented to the Emergency Department on February 10, 2024, with a diagnosis of agitation, violent behavior and for a psychiatric evaluation. There was no documentation of a nursing reassessment on February 10, 2024, from 16:47 until February 10, 2024, at 19:58 when the patient eloped. A review of MR5 on April 22, 2024, revealed a 54 year old who presented to the Emergency Department on February 14, 2024, with a diagnosis of back pain. There was no documentation of a nursing reassessment on February 14, 2024, from 13:26 until February 14, 2024, at 16:37 when the patient eloped. A review of MR8 on April 22, 2024, revealed a 43-year-old who presented to the Emergency Department on March 4, 2024, with a diagnosis of chest pain. There was no documentation of a nursing reassessment on March 4, 2024, from 14:26 until March 4, 2024, at 21:13 when the patient eloped. A review of MR9 on April 23, 2024, revealed a 44-year-old who presented to the Emergency Department on March 4, 2024, with a diagnosis of rectal pain. There was no documentation of a nursing reassessment on March 4, 2024, from 15:23 until March 4, 2024, at 17:19 when the patient eloped. A review of MR10 on April 23, 2024, revealed a 17-year-old who presented to the Emergency Department on March 9, 2024, with a diagnosis of mental health issues. There was no documentation of triage, a nursing assessment or reassessment on March 9, 2024, from 16:53 until March 9, 2024, at 17:00 when the patient eloped. A review of MR13 on April 23, 2024, revealed a 15-year-old who presented to the Emergency Department on March 20, 2024, with a diagnosis of surgical problems. There was no documentation of a nursing reassessment on March 20, 2024, from 09:48 until March 20, 2024, at 13:51 when the patient eloped. A review of MR14 on April 23, 2024, revealed a 24-year-old who presented to the Emergency Department on March 25, 2024, with a diagnosis of pregnancy complications. There was no documentation of a nursing reassessment on March 25, 2024, from 11:49 until March 25, 2024, at 15:05 when the patient eloped. A review of MR18 on April 23, 2024, revealed a patient who presented to the Emergency Department. Review on April 23, 2024, revealed, no documentation of triage or a nursing assessment on MR18 from arrival on January 1, 2024, at 23:07 until January 2, 2024 at 01:53, when it was discovered that MR18 left without being seen. On April 23, 2024, at 11:00 EMP2 confirmed the above.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 46390 This condition is not met as evidenced by: Based on a review of facility documentation, medical records (MR), and staff interview(s) (EMP) it was determined the facility failed to supervise the patient’s care to ensure the patient’s cardiac status was being monitored at all times for one of 20 medical records reviewed (MR1), and the facility failed to ensure frequent assessments for cardiac rhythms were completed in accordance with facility policy for 11 of 20 medical records reviewed (MR5, MR6, MR7, MR8, MR8, MR9, MR10, MR11, MR12, MR13, MR14). It was determined that the facility failed to supervise and ensure the patients’s care to ensure the patient’s cardiac status was being monitored at all times for one of 20 and frequent assessments for cardiac assessment for cardiac rhythms in accordance with facilty policy for 11 of 20 medical records. It was determined that the facility failed to ensure that the facility staff adhered to the policies and procedures of the hospital for cardiac monitoring alarm response in one of one medical records (MR1). Cross reference 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 46390 Based on a review of Facility documentation, medical records (MR), and staff interview(s) (EMP) it was determined the facility failed to supervise the patient’s care to ensure the patient’s cardiac status was being monitored at all times for 1 of 20 medical records reviewed (MR1), and the facility failed to ensure frequent assessments for cardiac rhythms were completed in accordance with facility policy for 11 of 20 medical records reviewed (MR5, MR6, MR7, MR8, MR8, MR9, MR10, MR11, MR12, MR13, MR14). On March 13, 2024, a review of the facility’s Protocol for Patient Management, last reviewed February 23, 2023, revealed, “In consideration of the Joint commission 2015 National Patient Safety Goal (NPSG), Excela Health has created this policy in order to facilitate appropriate alarm management and decrease instances of alarm fatigue and alarm nuisance. ...ALARM RESPONSE. Patient care staff must respond to alarms immediately. ...Patient care staff identifies the reason for the alarm the reason for the alarm, corrects the issue or notifies the appropriate individual when patient monitoring issues arise that are outside the clinicians’ scope of practice, ,,, DOCUMENTATION in EMR: All assessment and reassessment findings, Interpretation of the rhythm strips on admission, every 8 hours, and as needed. Alarms are functional, Any changes made to alarms, Any changes inpatient’s vital signs or cardiac rhythm...”. On March 13, 2024, a review of MR1 revealed the patient was a 74-year old admitted, via the Emergency Department on 2/21/24 with increased shortness of breath. The patient was recently diagnosed 2/14/24 with COVID-19 infection. The patient was at a Skilled Nursing Facility recovering from a broken arm and has a past medical history Hypertension, Hyperlipidemia, and alcoholism. The patient arrived on the nursing unit at 19:43. The initial cardiac rhythm at 19:43 is documented as Normal Sinus Rhythm. At 20:28, the charge nurse and primary nurse were notified that the patient was off the monitor. At 20:48 the patient was found on the floor when staff went to check a lead off monitor alarm. The patient’s intravenous line was pulled out and monitors were disconnected and the patient was not responsive but had a faint pulse, a code blue was called. Cardiac life-support was initiated and the patient had a return of spontaneous circulation. The patient was intubated and transferred to the ICU for further care. On 2/22/2024 neurology consult states patient with severe anoxic brain injury. 2/23/2024 the patient’s prognosis discussed with family and family made patient comfort measure only and patient was removed from ventilatory support. The patient was prounced deceased at 17:45 on 2/23/2024. A review of MR5, revealed a 92 year old admitted, via the Emergency Department with a recent fall, left shoulder pain and a left humerus fracture. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 11, 2024, 23:43 until March 13, 2024 at 0:07. A review of MR6, revealed a 82 year old admitted, via the Emergency Department with a recent diagnosis of weakness and Atrial Fib. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 11, 2024, 23:50 until March 12, 2024 at 23:37. A review of MR7, revealed a 72 year old admitted, via the Emergency Department with a recent diagnosis of difficulty breathing. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 12, 2024, 08:22 until March 12, 2024 at 22:10. A review of MR8, revealed a 72 year old admitted, via the Emergency Department with a recent diagnosis of shortness of breath. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 12, 2024, 07:57 until March 12, 2024 at 23:53. A review of MR9, revealed a 80 year old admitted, via the Emergency Department with a recent diagnosis of altered mental status. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 11, 2024, 23:55 until March 12, 2024 at 23:41. A review of MR10, revealed a 85 year old admitted, via the Emergency Department with a recent diagnosis of confusion. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 11, 2024, 21:00 until March 12, 2024 at 23:15. A review of MR11, revealed a 55 year old admitted, via the Emergency Department with a recent diagnosis of cough, difficulty breathing. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 12, 2024, 08:52 until March 12, 2024 at 22:06. A review of MR12, revealed a 49 year old admitted, via the Emergency Department with a recent diagnosis of hallucinations, difficulty urinating. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 12, 2024, 09:04 until March 12, 2024 at 22:16. A review of MR13, revealed a 81 year old admitted, via the Emergency Department with a recent diagnosis of weakness. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 12, 2024, 09:45 until March 12, 2024 at 22:23. A review of MR14, revealed a 78 year old admitted, via the Emergency Department with a recent diagnosis of chest pain, Atrial Fib. Review on March 13, 2024, revealed no documentation of a telemetry rhythm from March 12, 2024, 09:49 until March 12, 2024 at 21:42. Interview with EMP5 at 15:00 on March 13, 2024, confirmed there was no documentation of cardiac telemetry rhythms as per facility policy.”

“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: 46390 Based on a review of facility documentation, medical record (MR), and staff interview (EMP), it was determined the facility failed to ensure staff adhered to the policies and procedures of the hospital for cardiac monitoring alarm response in one of one medical records (MR1). Findings include: On March 13, 2024, a review, of the facility’s Protocol for Patient Management, last reviewed February 23, 2023, revealed, “In consideration of the Joint commission 2015 National Patient Safety Goal (NPSG), Excela Health has created this policy in order to facilitate appropriate alarm management and decrease instances of alarm fatigue and alarm nuisance. ...ALARM RESPONSE. Patient care staff must respond to alarms immediately. ...Patient care staff identifies the reason for the alarm the reason for the alarm, corrects the issue or notifies the appropriate individual when patient monitoring issues arise that are outside the clinicians’ scope of practice, ,,, DOCUMENTATION in EMR: All assessment and reassessment findings, Interpretation of the rhythm strips on admission, every 8 hours, and as needed. Alarms are functional, Any changes made to alarms, Any changes inpatient’s vital signs or cardiac rhythm...”. On March 13, 2024, a review of MR1 revealed the patient was a 74-year old admitted, via the Emergency Department on 2/21/24 with increased shortness of breath. The patient was recently diagnosed 2/14/24 with COVID-19 infection. The patient was at a Skilled Nursing Facility recovering from a broken arm and has a past medical history Hypertension,.Hyperlipidemia, and alcoholism. The patient arrived on the nursing unit at 19:43. The initial cardiac rhythm at 19:43 is documented as Normal Sinus Rhythm. At 20:28, the charge nurse and primary nurse were notified that the patient was off the monitor. At 20:48 the patient was found on the floor when staff went to check a lead off monitor alarm. The patient’s intravenous line was pulled out and monitors were disconnected and the patient was not responsive but had a faint pulse, a code blue was called. Cardiac life-support was initiated and the patient had a return of spontaneous circulation. The patient was intubated and transferred to the ICU for further care. On 2/22/2024 neurology consult states patient with severe anoxic brain injury. 2/23/2024 the patient’s prognosis discussed with family and family made patient comfort measure only and patient was removed from ventilatory support. The patient was prounced deceased at 17:45 on 2/23/2024. Interview with EMP5, on March 13, 2024, at 14:20, confirmed the above findings.”