Regional Hospital of Scranton

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 21559 Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to re-assess patients pain in the Emergency Department (ED) as per facility policy for four of twenty-one (21) medical records reviewed (MR1, MR12, MR13, MR14). Findings include: Review on July 22, 2025, of facility, “ Pain Management Policy,” published date March 7, 2025, revealed “ I. Purpose: A. The purpose of this policy is to guide the treatment of pain. II. Policy: A. A patient ’ s pain level will be assessed and reassessed, and the patients and their family will be taught pain management on an ongoing basis. (Admission, treatment and discharge). Patient/family education is documented in the medical record ... C. Interventions may be pharmacological or non-pharmacological, such as ice, heat, elevation, repositioning, relaxation techniques, distraction, massage or deep breathing. III. Procedures: ... F. Document specific intervention/s on the Electron Medical Record that either improve patient comfort or were ot effective.... G. Re-assess the level of pain after intervention using the same pain rating scale used for initial assessment. Timing of re-assessment: 1. Within 30 minutes for parental intervention. 2. 60 minutes for oral analgesic 3. If the intervention is effective, continue to monitor patient. 4. If the intervention is ineffective, report to the Physician using the appropriate scale and evaluate other options: Example: Comfort measures, patient plan of care, medications, physician notification. 5. Document any additional information in the patient ’ s medical record. ... “ Review of MR1 on July 22, 2025, revealed this patient presented to the ED on June 5, 2025, at 1604 by their OBGYN to rule out an ectopic pregnancy. MR1 was assessed and met the Acuity level of 2. MR1 reported a pain level of 8, on a scale of 1 to 10 with 10 being the worst pain, in their bilateral lower abdomen and was administered Tylenol 1000 milligrams (mg) by mouth for pain at 1851. There was no documentation in MR1 indicating the facility re-evaluated this patient’s pain level after 60 minutes. Interview on July 22, 2025, with EMP1, confirmed the above findings. Review of MR12 on July 22, 2025, revealed this patient presented to the ED on July 18, 2025, at 1136, with a chief complaint of being kicked in the abdomen. Documentation revealed MR12 was 8 weeks pregnant and was experiencing lower abdominal pain. MR12 was assessed and met the Acuity level of 3. MR12 reported a pain level of 6, on a scale of 1 to 10 with 10 being the worst pain, with moderate cramping pain in the lower abdomen. MR12 was discharged home on July 18, 2025, at 1645. There was no documentation in MR12 indicating nursing staff provided any pain interventions for this patient ’ s pain rating of 6. There was no re-evaluation of MR12’s pain level of 6 for five hours while the patient was in the ED. Review of MR13 on July 22, 2025, revealed this patient presented to the ED on July 20, 2025, at 1518, with a chief complaint of abdominal pain. MR13 was assessed and met the Acuity level of 3. MR13 reported a pain level of 5, on a scale of 1 to 10 with 10 being the worst pain, with moderate pain of the lower abdomen. MR13 was discharged home on July 20, 2025, at 1844. There was no documentation in MR13 indicating nursing staff provided any pain interventions for this patient ’ s pain rating of 5. There was no re-evaluation of MR13’s pain level of 5 for 3.5 hours while the patient was in the ED. Review of MR14 on July 22, 2025, revealed this patient presented to the ED on July 16, 2025, at 1406. MR14 was sent from the physician office for dehydration, compliant of chills, nausea and a severe sunburn. MR14 was assessed and met the Acuity level of 3. MR14 reported a pain level of 7, on a scale of 1 to 10 with 10 being the worst pain, with generalized pain and burning of the sunburn. MR14 was discharged home on July 16, 2025, at 1722. There was no documentation in MR14 indicating nursing staff provided any pain interventions for this patient ’ s pain rating of 7. There was no re-evaluation of MR14’s pain level of 7 for three hours while the patient was in the ED. Interview on July 22, 2025, with EMP3, confirmed the above findings.”

“CRITERIA FOR MEDICAL STAFF PRIVILEGING CFR(s): 482.22(c)(6) [The bylaws must:] Include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges. For distant-site physicians and practitioners requesting privileges to furnish telemedicine services under an agreement with the hospital, the criteria for determining privileges and the procedure for applying the criteria are also subject to the requirements in §482.12(a)(8) and (a)(9), and §482.22(a)(3) and (a)(4). This Standard is not met as evidenced by: 36696 Based on review of facility documents, medical records (MR), credential files (CF), and staff interview (EMP), it was determined the facility failed to ensure a physician had privileges for ventilator management for one of six credential files reviewed (CF2). Findings include: Review on July 10, 2024, of the “Medical Staff Bylaws Of Regional Hospital Of Scranton,” dated November 29, 2023, revealed “...4.2 Active Staff ...4.2(b) Prerogatives ... (2) To exercise only such delineated clinical privileges as are granted to him/her pursuant to Article VII; ... 6.3(e) Description of Initial Clinical Privileges Medical Staff appointments or reappointments shall not confer any clinical privileges or rights to practice in the Hospital. Each Practitioner who is appointed to the Medical Staff of the Hospital shall be entitled to exercise only those clinical privileges specifically granted by the Board. ... ARTICLE VII - Determination Of Clinical Privileges 7.1 Exercise Of Privileges Every Practitioner or AHP providing direct clinical services at this Hospital shall, in connection with such practice and except as provided in Section 7.5, be entitled to exercise only those clinical privileges or services specifically granted to him/her by the Board. Said privileges must be within the scope of the license authorizing the Practitioner or AHP to practice in this state and consistent with any restrictions thereon. The Board shall approve the list of specific privileges and limitations for each category of Practitioner and AHP, and each Practitioner or AHP shall bear the burden of establishing his/her qualifications to exercise each individual privilege granted. ...” Review on July 10, 2024, of CF2, revealed CF2’s appointment was January 25, 2023, until January 24, 2025. CF2 was granted nephrology privileges. Interview on July 10, 2024, with EMP9, at approximately 1:10 PM, confirmed the above findings. Review on July 10, 2024, of MR2, revealed a verbal order from CF2 for ventilator settings on July 1, 2024, at 13:39 PM. Interview on July 10, 2024, with EMP3, at approximately 1:30 PM confirmed the above findings. Continued interview on July 10, 2024, with EMP9, at approximately 1:45 PM, confirmed CF2 does not have privileges for ventilator care.”

“ORDERS FOR RESPIRATORY SERVICES CFR(s): 482.57(b)(3) Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital’s medical staff to order the services in accordance with hospital policies and procedures and State laws. This Standard is not met as evidenced by: 36696 Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure verbal orders were co-signed by a physician within 24 hours for four of four medical records reviewed (MR1, MR2, MR3, and MR4). Findings include: Review on July 10, 2024, of facility, “Regional Hospital Of Scranton Rules And Regulations,” approved November 29, 2023, revealed, “...Verbal Orders Verbal orders are discouraged and should be reserved for those situations when it is impossible or impractical for the practitioner to write the order or enter it in a computer. Verbal orders must comply with the following criteria: ...d. All verbal orders must be signed by the ordering practitioner or another practitioner involved in the patient’s care within 24. ...” Review on July 10, 2024, of MR1, revealed a verbal order was given by CF1 on June 29, 2024, at 16:08 PM to change the FIO2 to 50% and wean per respiratory vent management protocol, wean O2 to keep sats 94-95%. No documentation the verbal order was co-signed by a physician within 24 hours. Continued review of MR1, revealed a verbal order was given by CF1 on July 1, 2024, at 16:38 PM, for Ventilator Mode SIMV/IMV Rate 12 Tidal volume (ml) 450 FIO2 30 Peep (cmH2O) 5 Pressure Support (cmH2O) 5 Constant Indicator Yes Special Instructions wean per resp vent management protocol, wean O2 to keep sats 94-95%. No documentation the verbal order was co-signed by a physician within 24 hours. Interview on July 10, 2024, with EMP3, at approximately 1:20 PM, confirmed the above findings. Review on July 10, 2024, of MR2, revealed a verbal order was given by CF1 on June 30, 2024, at 08:04 AM, for Ventilator Mode AC Rate (BPM) 24 Tidal volume (mL) 600 FIO2 100 PEEP (cmH2O) 5 Constant Indicator Yes, may titrate FiO2 to keep O2 saturation equal to or greater than 92%. No documentation the verbal order was co-signed by a physician within 24 hours. Interview on July 10, 2024, with EMP3, at approximately 1:40 PM, confirmed the above findings. Review on July 11, 2024, of MR3, revealed a verbal order was given by CF1 on June 25, 2024, at 16:02 PM, for Ventilator Mode CPAP FIO2 40 Peep (cmH2O) 5 Pressure Support (cmH2O) 5 constant Indicator Yes Special Instructions Adjust FiO2 to maintain O2 saturation greater than or equal to 92%. No documentation the verbal order was co-signed by a physician within 24 hours. Continued review on July 11, 2024, of MR3, revealed a verbal order was given by CF1 on June 30, 2024, at 11:13 AM, for Ventilator Mode AC Rate (BPM) 18, Tidal volume (mL) 450 FIO2 30 PEEP (cmH2O) 5 Constant Indicator Yes Difference in Minutes -1. No documentation the verbal order was co-signed by a physician within 24 hours. Interview on July 11, 2024, with EMP3, at approximately 9:30 AM, confirmed the above findings. Review on July 11, 2024, of MR4, revealed a verbal order was given by CF1 on July 4, 2024, at 19:16 PM, for Ventilator Mode AC Rate (BPM) 18 Tidal volume (mL) 440 FIO2 40 PEEP (cmH2O) 5 Constant Indicator Yes Difference in Minutes -1. No documentation the verbal order was co-signed by a physician within 24 hours. Continued review of MR4, revealed a verbal order was given by CF1 on July 5, 2024, at 14:16 PM, for Ventilator Mode CPAP FIO2 40 PEEP (cmH2O) 5 Pressure Support (cmH2O) 5 Constant Indicator Yes. No documentation the verbal order was co-signed by a physician within 24 hours. Interview on July 11, 2024, with EMP3 confirmed the above findings for MR4.”