PRINTED: 9/29/2017

FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0000 INITIAL COMMENT P 0000

This report is the result of an unannounced special

monitoring survey (XGN311) initiated on July 3,

2017 and completed on July 21, 2017, at Milton S
Hershey Medical Center. It was determined that
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.

P 0351 P 0351

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE: (X6) DATE:

State Form XGN311 IF CONTINUATION SHEET Page 1 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 1 P 0351

103.22 (b)(6) IMPLEMENTATION Completion

1. On July 6 and 14, 2017, the Penn Date:
(6) The patient has the right to
State Health Milton S. Hershey 08/31/2017
expect emergency procedures
Medical Center (HMC) emergency Status:
to be implemented without department (ED) nurse manager APPROVED
unnecessary delay. included the "Brain Attack Protocol" Date:
in the ED nurse manager's weekly 08/24/2017
This REGULATION is not met as evidenced by:
electronic communication to all ED
staff.

2. On July 12, 2017, the

involved HMC emergency medicine
(EM) physician was interviewed by
the EM department chair. The
criteria to activate a "Brain
Attack Protocol" was reviewed and
understanding was acknowledged.

3. On July 14, 2017, the ED

nurse manager emailed the "Brain

Attack Protocol" to all of the ED
nursing staff for review. A
signature log will confirm their
review by August 25, 2017.

4. On July 19, 2017, the EM faculty

physicians were re-educated by the EM

department chair on the "Brain Attack

Protocol" at a faculty meeting

State Form XGN311 IF CONTINUATION SHEET Page 2 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 2 P 0351

5. On July 20, 2017, the ED nurse

manager met with the ED Integrated
Council and reviewed the "Brain
Attack Protocol."

6. On July 20, 2017, the ED nurse

manager posted the "Brain Attack
Protocol" in both triage bays in the

ED.

7. On August 17, 2017, an HMC

pediatric inpatient specialist will
educate the pediatric residents by
lecture on appropriate indications for
calling a Pediatric Rapid Response to
escalate care for pediatric patients

showing signs of clinical

deterioration. An attendance log will
confirm their participation. Those
unable to attend the lecture will
receive the education via our
electronic course management
system with an expectation that it
will be completed by September 1,
2017. Residents who are
non-compliant with the September 1,

2017 deadline will receive

State Form XGN311 IF CONTINUATION SHEET Page 3 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 3 P 0351

counselling from the residency

program director. The residency
program director will require the
resident to complete the training in
person under their supervision no
later than September 8, 2017.

8. By August 23, 2017, the HMC

pediatric intermediate medical care

unit (PIMCU) nurse manager will

have one-to-one meetings with the
full-time and part-time nursing staff

to educate them on the Pediatric

Rapid Response Team process and
the escalation of care process. PRN

staff may have this education

provided via a telephone
conversation due to their infrequent
work schedule. Staff will sign an
attestation sheet acknowledging the

review of this information.

9. By August 31, 2017, the PIMCU

nursing staff will review the Pediatric

Rapid Response Team process and

the escalation of care process during
their annual performance evaluation
sessions with nursing leadership.

State Form XGN311 IF CONTINUATION SHEET Page 4 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 4 P 0351

The PIMCU nursing staff will sign

an attestation sheet acknowledging
the review of this information. New
PIMCU nursing staff will receive this

information as part of the

departmental new hire orientation
process.

State Form XGN311 IF CONTINUATION SHEET Page 5 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 5 P 0351

Based on a review of medical records (MR), facility

documents, and staff interviews (EMP), it was

determined that the facility failed to implement
emergency procedures without unnecessary delay
for two of two occurances (MR1 and MR11).

Findings include:

A review on July 6, 2017 of MR1's nursing note,

dated June 6, 2017 at 12:30 revealed, "...full head

to toe assessment completed at this time. pt's HR

elevated in 170's...Pt appears lethargic at this
time...Pt's upper airway sounded Rhonchitic, nursing

performed Chest PT, oral/nasal suctioning without

improvement..."
A review on July 6, 2017 of MR1's nursing note,
dated June 6, 2017 at 13:15 revealed, "...Peds team

assessed pt with nursing's concerns for elevated HR,

lethargy, increased WOB, junky airway. Team

ordered RVP at this time, along with Chest x-ray.

will cont to monitor..."

A review on July 6, 2017 of MR1's nursing note,
dated June 6, 2017 at 15:15 revealed, "Rec'd call

State Form XGN311 IF CONTINUATION SHEET Page 6 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 6 P 0351

from PCA regarding pt's mom's concern for

temperature. nursing entered room, pt was red in the

face, hot to the touch on head, neck, chest, and cool

to lower extremities and feet. PCA took rectal temp

of 42.3 Celsius. Upper thighs looked mottled, lips

were blue, pt had noisy stridor airways. Pt was

obtunded, not responding to painful stimuli or sternal

rub. Paged team. Resident came to bedside, and

then called Rapid for more hands..."

A review on July 6, 2017 of MR1 "Pediatric
Response Team (PRRT)/Pediatric Code Blue
(PCB) Event Form revealed that a Pediatric Rapid

Response Team was called on June 6, 2017 at

15:30. The PRRT team arrived at 15:35. The
patient was then transferred to the PICU.
A review on July 6, 2017 of facility policy,
"Pediatric Rapid Response Team (PRRT)," effective
March 2014, revealed, " ...Patients who might need

the PRRT are those with worrisome changes in

neurologic, cardiac, or respiratory status. Examples

include, but are not limited to: acute mental status

changes, dyspnea, hypoxemia, arrhythmia's and

State Form XGN311 IF CONTINUATION SHEET Page 7 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 7 P 0351

shock... "
A review of the facility's investigation of this incident,

dated June 30, 2017, revealed "...Patient

deteriorated to shock with DIC and AKI in IMC

with delayed escalation of care. Patient mottled,

obtunded, RRT called. Patient in septic shock

upgraded to ICU level of care. Brain death criteria

met several days later..."

Interview on July 6, 2017 at approximately 2:00PM
with EMP7 confirmed that the RRT should have
been called much earlier, about noon. EMP7 further
stated that staff are resistant to call. EMP7 went on

to say that the RRT was called by the medical team

to get an iStat only, and that the RRT was not called

for the right reason.

A review on July 21, 2017 of MR11 revealed an

ED Triage Form dated June 11, 2017 at 9:56 PM
that referred to the patient as "not making sense"
and "slow to follow commands/difficulty following
commands." An interdisciplinary nursing narrative
dated June 11, 2017 at 9:58 PM referred to the
patient's inability to grasp the RN's hand with their

State Form XGN311 IF CONTINUATION SHEET Page 8 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 8 P 0351

left hand. "No brain attack called at this time." An

interdisciplinary nursing narrative dated June 11,

2017 at 10:30 PM (32 minutes later) stated,
"...discussed with ED attending need to call brain
attack at this time, deferred by Dr. [name redacted].
An interdisciplinary nursing narrative dated June 12,

2017 at 00:15AM (approximately 2 hours and 15

minutes since the patient was assessed in triage)
stated, "change of attending at this time. discussed
need to call ED brain attack at this time. Awaiting

further orders..."

Further review of MR11 revealed a

Reexamination/Reevaluation note that stated,
"Signed out to Dr. [name redacted] at 0020 suspect
TIA or hyperglycemia, acute encephalopathy admit.

No evidence of acute CVA by physical or CT at

time of signout..." Further review of MR11 revealed

another Reexamination/Reevaluation note dated

June 12, 2017 at 0031AM. "...Patient examined by

me at this time, awake, confused to events has

complete L hemianopsia, drift in L leg, L sided
neglect, possible subtle L facial drop, and ataxia B/L

State Form XGN311 IF CONTINUATION SHEET Page 9 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 9 P 0351

upper and lower extremity, stroke alert called

immediately by me...patient outside window for
TPA...Diagnosis: Acute right MCA stroke. Acute
ill-defined cerebrovascular disease..."
A review on July 21, 2017 of facility policy, "Brain
Attack Protocol," effective February, 2017,
revealed, " ...Protocol. Brain attack activation
criteria for ED and Inpatient: 1. Patients presenting
with onset of symptoms consistent with acute stroke
less than 12 hours including, but not limited to: a)
Weakness of an arm and/or leg on one side of the
body. b) Facial droop. c) Difficulty with speech. d)
Numbness in face, arm, and/or leg. e) severe
headache. f) Change in level of consciousness. g)
Vision loss. h) Trouble walking, loss of balance or
coordination. i) Dizziness with other neurologic
symptoms..." Further, an RN can activate the brain
attack protocol per policy, which will initiate the
brain attack order set. The physician should then be
immediately informed.
Interview on July 24, 2017 at approximately 2:45
PM with EMP2 confirmed that the case was
reviewed via internal event report by EMP17 on

State Form XGN311 IF CONTINUATION SHEET Page 10 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 10 P 0351

June 30, 2017, who then determined that the brain

attack should have been recognized and called
earlier by EMP18, who was a physician that cared
for the patient when they first arrived at the ED.

State Form XGN311 IF CONTINUATION SHEET Page 11 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0351 Continued from page 11 P 0351

P 0352 P 0352

State Form XGN311 IF CONTINUATION SHEET Page 12 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0352 Continued from page 12 P 0352

103.22 (b)(7) IMPLEMENTATION Completion

1. On July 6 and 14, 2017, the Penn Date:
(7) The patient has the right to good
State Health Milton S. Hershey 08/31/2017
quality care and high professional
Medical Center (HMC) emergency Status:
standards that are continually department (ED) nurse manager APPROVED
maintained and reviewed. included the "Brain Attack Protocol" Date:
in the ED nurse manager's weekly 08/24/2017
This REGULATION is not met as evidenced by:
electronic communication to all ED
staff.

2. On July 12, 2017, the

involved HMC emergency medicine
(EM) physician was interviewed by
the EM department chair. The
criteria to activate a "Brain
Attack Protocol" was reviewed and
understanding was acknowledged.

3. On July 14, 2017, the ED

nurse manager emailed the "Brain

Attack Protocol" to all of the ED
nursing staff for review. A
signature log will confirm their
review by August 25, 2017.

4. On July 19, 2017, the EM

faculty physicians were re-educated

by the EM department chair on the

"Brain Attack Protocol" at a

faculty meeting.

State Form XGN311 IF CONTINUATION SHEET Page 13 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0352 Continued from page 13 P 0352

5. On July 20, 2017, the ED nurse

manager posted the "Brain Attack
Protocol" in both triage bays in the

ED.

6. On July 20, 2017, the ED nurse

manager met with the ED Integrated
Council and reviewed the "Brain
Attack Protocol".

7. On August 17, 2017, an HMC

pediatric inpatient specialist will
educate the pediatric residents by
lecture on appropriate indications for
calling a Pediatric Rapid Response to
escalate care for pediatric patients

showing signs of clinical

deterioration. An attendance log will
confirm their participation. Those
unable to attend the lecture will
receive the education via our
electronic course management
system with an expectation that it
will be completed by September 1,
2017. Residents who are
non-compliant with the September 1,

2017 deadline will receive

counselling from the residency

State Form XGN311 IF CONTINUATION SHEET Page 14 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0352 Continued from page 14 P 0352

program director. The residency

program director will require the
resident to complete the training in
person under their supervision no
later than September 8, 2017.

8. By August 23, 2017, the HMC

pediatric intermediate medical care

unit (PIMCU) nurse manager will

have one-to-one meetings with the
full-time and part-time nursing staff

to educate them on the Pediatric

Rapid Response Team process and
the escalation of care process. PRN

staff may have this education

provided via a telephone
conversation due to their infrequent
work schedule. Staff will sign an
attestation sheet confirming review

of this information.

9. By August 25, 2017, the ED

nurse manager will educate via
policy review, all ED nursing staff on

stat medications outlined by HMC

policy "Medication Administration
M-1CPMN." This education will
occur via email, shift safety huddles
and staff meetings. A signature log

State Form XGN311 IF CONTINUATION SHEET Page 15 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0352 Continued from page 15 P 0352

will confirm review of this policy.

10. By August 25, 2017, an alert

stating "must obtain from pharmacy"
will be created in the electronic
health record for when Kcentra is
ordered. This will alert the nursing
staff that this medication is not
inventoried in the Pyxis automated
medication dispensing system and
that they must contact pharmacy to
obtain the medication.

11. By August 25, 2017, ED nurse

manager will educate all ED nursing
staff that they must have contact via

telephone or face-to-face
conversation with the pharmacist
when a stat order for Kcentra has
been placed. This education will
occur via email, shift safety huddles

and staff meetings.

12. By August 25, 2017, the HMC

medication safety and compliance
pharmacist will modify the HMC
policy "Medication Order
Turn-around Times" to align with

State Form XGN311 IF CONTINUATION SHEET Page 16 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0352 Continued from page 16 P 0352

the "Medication Administration

M-1CPMN" policy and ensure
education of all HMC inpatient
pharmacists and technicians via
policy review, highlighting the stat
medication policy statement. This
education will occur via email and
staff meetings. An electronic
tracking log will confirm review of

this revised policy.

13. By August 25, 2017, the

medication safety and compliance
pharmacist will modify the Factor
Dispensing Accountability form and
review with all inpatient pharmacists
and technicians, via email and staff

meetings, the need to accurately

complete the Factor Dispensing
Accountability form for blood factor
medication (including Kcentra). This

form documents the time the

medication is received on the unit
and ensures documentation of
transactions from the pharmacy to
the nursing units.

14. By August 25, 2017, the

medication safety and compliance

State Form XGN311 IF CONTINUATION SHEET Page 17 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0352 Continued from page 17 P 0352

pharmacist will initiate an audit of 30

random Factor Dispensing

Accountability forms per month, for
two months, to ensure compliance of
recording Factor drug transactions.

The medication safety and

compliance pharmacist will address
any instances of non-compliance
through the progressive discipline
process.

15. On August 25, 2017, the ED

nursing staff will be educated on the

drug Kcentra by an information

sheet. ED nursing staff will sign an
attestation sheet confirming review

of this information.

16. By August 31, 2017, the PIMCU

nursing staff will review the Pediatric

Rapid Response Team process and

the escalation of care process during
their annual performance evaluation
sessions with nursing leadership.
The PIMCU nursing staff will sign
an attestation sheet acknowledging
the review of this information. New
PIMCU nursing staff will receive this

information as part of the

State Form XGN311 IF CONTINUATION SHEET Page 18 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0352 Continued from page 18 P 0352

departmental new hire orientation

process.

State Form XGN311 IF CONTINUATION SHEET Page 19 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0352 Continued from page 19 P 0352

Based on a review of facility documentation,

medical records (MR) and interviews with staff
(EMP), it was determined the facility failed to ensure

that each patient had the right to good quality care.

Findings include:

Based on the findings cited in this report, the facility

failed to consistently conduct timely assessments,

follow physician's orders, follow established policies

and procedures and provide appropriate care to

patients who were admitted with and/or developed
conditions which led to significant impairment or
death. As evidenced by these findings, the facility
failed to consistenly provide high quality care and

protect and promote the rights of patients.

State Form XGN311 IF CONTINUATION SHEET Page 20 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0924 P 0924

State Form XGN311 IF CONTINUATION SHEET Page 21 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0924 Continued from page 21 P 0924

109.23 (b)(1-5) WRITTEN NURSING CARE POLICIES Completion

1. By August 25, 2017, an alert Date:
109.23 stating "must obtain from pharmacy" 08/25/2017
(b) Nursing care policies and
will be created in the Penn State Status:
procedures shall be consistent with
Health Milton S. Hershey Medical APPROVED
professionally recognized standards of
Center (HMC) electronic health Date:
nursing practice and shall be in 08/24/2017
record for when Kcentra is ordered.
accordance with the Professional
This will alert the HMC nursing
Nursing Law and regulations
staff that this medication is not
promulgated by the State Board of
inventoried in the Pyxis automated
examiners. These policies shall
medication dispensing system and
include procedures for the following:
that they must contact pharmacy to
(1) noting diagnostic and
obtain the medication.
therapeutic orders
(2) assigning the nursing 2. By August 25, 2017, HMC emergency
care of patients department (ED) nurse manager will
(3) infection control educate all ED nursing staff that they
(4) patient safety
must have contact via telephone or
(5) implementing orders for
face-to-face conversation with the
medication and treatment, consistent pharmacist when a stat order for

with 107.61-107.65 of this subpart. Kcentra has been placed. This education

will occur via email, shift safety

This REGULATION is not met as evidenced by: huddles and staff meetings. A signature

log will confirm review of this policy.

3. On August 25, 2017, the ED

nursing staff will be educated on

the drug Kcentra by an information

State Form XGN311 IF CONTINUATION SHEET Page 22 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0924 Continued from page 22 P 0924

sheet. ED nursing staff will sign an

attestation sheet confirming review

of this information.

4. By August 25, 2017, the HMC

medication safety and compliance
pharmacist will modify the HMC
policy "Medication Order
Turn-around Times" to align with
the "Medication Administration
M-1CPMN" policy and ensure
education of all HMC inpatient
pharmacists and technicians via
policy review, highlighting the stat
medication policy statement. This
education will occur via email and
staff meetings. An electronic
tracking log will confirm review of

this revised policy.

5. By August 25, 2017, the ED

nurse manager will educate via
policy review, all ED nursing staff on

stat medications outlined by HMC

policy "Medication Administration
M-1CPMN." This education will
occur via email, shift safety huddles
and staff meetings. A signature log
will confirm review of this policy.

State Form XGN311 IF CONTINUATION SHEET Page 23 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0924 Continued from page 23 P 0924

6. By August 25, 2017, the HMC

medication safety and compliance
pharmacist will modify the Factor
Dispensing Accountability form and
review with all HMC inpatient
pharmacists and technicians, via
email and staff meetings, the need to

accurately complete the Factor

Dispensing Accountability form for
blood factor medication (including
Kcentra). This form documents the
time the medication is received on
the unit and ensures documentation
of transactions from the pharmacy to

the nursing units.

7. By August 25, 2017, the

medication safety and compliance
pharmacist will initiate an audit of 30

random Factor Dispensing

Accountability forms per month, for
two months, to ensure compliance of
recording Factor drug transactions.

The medication safety and

compliance pharmacist will address
any instances of non-compliance
through the progressive discipline
process.

State Form XGN311 IF CONTINUATION SHEET Page 24 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0924 Continued from page 24 P 0924

Based on a review of medical records (MR), facility

documents, and staff interview(EMP), it was

determined that the facility failed to follow their

adopted policy regarding administration of

medication for one of one occurrence (MR2).

Findings include:

A review of MR2 revealed the patient was admitted

to the ED on July 22, 2017 at approximately 4:40
AM . The patient presented to ED after a fall from
standing position at approximately 3:30AM. The
patient was ordered Kcentra stat(for urgent reversal

of acquired coagulation factor deficiency induced by

Vitamin K antagonist, e.g.. Warfarin, therapy in

adult patients with acute major bleeding). Although

the medication was ordered stat at 0547 and

confirmed by the pharmacy at 0649, it was not
given until 0836 after the patient was transferred to

the ICU (1 hour 47 minutes after the medication

was ordered). Upon admission to the ICU, the
patient's condition worsened. A head CT showed

State Form XGN311 IF CONTINUATION SHEET Page 25 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0924 Continued from page 25 P 0924

an increase in the size of the subdural.....the patient

later died; the cause of death was the SDH.
A review on July 6, 2017 of facility policy, "
Medication Administration Policy, " effective
August 2016, revealed, " ...Scheduled Medication
Administration Time...d. Time-critical scheduled
medications are those for which early or late
administration might cause harm or have significant
negative impact on the intended therapeutic or
pharmacological effect. Time-critical scheduled
medications are:...vii. Stat medications...e.
Time-critical scheduled medications are to be
administered within 30 minutes before or after
scheduled dosing time for a total window of one
hour... "
A review on July 6, 2017 of facility email dated June
28, 2017, revealed a conversation between a
pharmacist and a pharmacy tech about who
delivered the medication and if there was a delay.
"...It was kcentra, right? {name redacted} took it to
the ED and the patient had transferred so he took it
to Neuro icu, where the patient transferred to..."

State Form XGN311 IF CONTINUATION SHEET Page 26 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0924 Continued from page 26 P 0924

The pharmacist then responded, "...Do you

remember did you have to wait for him to come
pick it up?..." The pharmacy tech then responded,
"...Yes. But the RN in the ED said she wasn't going

to give it right away cause of change of shift..."

Interview on July 5, 2017 at approximately 11:55

am with EMP4 and EMP5 confirmed that the

pharmacist verified the order at 0649, but that there

was no documentation of when the medication left

the pharmacy.

State Form XGN311 IF CONTINUATION SHEET Page 27 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0924 Continued from page 27 P 0924

P 0940 P 0940

State Form XGN311 IF CONTINUATION SHEET Page 28 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0940 Continued from page 28 P 0940

109.61 DRUG ADMINISTRATION PROCEDURES Completion

1. By August 25, 2017, the Penn Date:
109.61 Medication or treatment State Health Milton S. Hershey 08/25/2017
Medical Center (HMC) medication Status:
Medication or treatment shall be safety and compliance pharmacist APPROVED
administered only upon written and will modify the HMC policy Date:
signed orders of a practitioner and in "Medication Order Turn-around Times" 08/22/2017
accordance with the provisions of to align with the "Medication
107.61-107.65 of this title. Administration M-1CPMN" policy and

ensure education of all HMC

This REGULATION is not met as evidenced by: inpatient pharmacists and

technicians via policy review,

highlighting stat medication policy

statement. This education will occur

via email and staff meetings. An

electronic tracking log will confirm

review of this revised policy.

2. By August 25, 2017, the

emergency department (ED) nurse

manager will educate via policy

review, all ED nursing staff on stat

medications outlined by HMC policy

"Medication Administration M-1CPMN."

This education will occur via email,

shift safety huddles and staff

meetings. A signature log will

confirm review of this policy.

3. By August 25, 2017, an alert

State Form XGN311 IF CONTINUATION SHEET Page 29 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0940 Continued from page 29 P 0940

stating "must obtain from pharmacy"

will be created in the electronic
health record for when Kcentra is
ordered. This will alert the nursing
staff that this medication is not
inventoried in the Pyxis automated
medication dispensing system and
that they must contact pharmacy to
obtain the medication.

4. By August 25, 2017, ED nurse

manager will educate all ED nursing

staff that they must then have

contact via telephone or
faceto-face conversation with the
pharmacist when a stat order for
Kcentra has been placed. This
education will occur via email, shift
safety huddles and staff meetings.

State Form XGN311 IF CONTINUATION SHEET Page 30 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0940 Continued from page 30 P 0940

Based on review of medical records (MR), facility

policy, and interview with staff (EMP), it was
determined a medication order was not administered
according to signed orders of a practitioner for one

of one occurrence (MR2).

Findings include:

A review on July 6, 2017 of MR2 revealed that

Kcentra (for urgent reversal of acquired coagulation

factor deficiency induced by Vitamin K antagonist,

eg. Warfarin, therapy in adult patients with acute

major bleeding) was ordered STAT in the ED at

0547. The order was confirmed by pharmacy at
0649, but was not given until 0836, after the patient

was transferred to the ICU. Upon admission to the

ICU, the patient's condition worsened. A head CT

showed increase in size of SDH (subdural

hematoma). The patient later died from their SDH.

A review on July 6, 2017 of facility policy, "

Medication Administration Policy, " effective
August 2016, revealed, " ...Scheduled Medication

State Form XGN311 IF CONTINUATION SHEET Page 31 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0940 Continued from page 31 P 0940

Administration Time...d. Time-critical scheduled

medications are those for which early or late

administration might cause harm or have significant

negative impact on the intended therapeutic or

pharmacological effect. Time-critical scheduled
medications are:...vii. Stat medications...e.
Time-critical scheduled medications are to be
administered within 30 minutes before or after
scheduled dosing time for a total window of one

hour... "
A review on July 6, 2017 of facility email dated June

28, 2017, revealed a conversation between a

pharmacist and a pharmacy tech about who
delivered the medication and if there was a delay.
"...It was kcentra, right? {name redacted} took it to

the ED and the patient had transferred so he took it

to Neuro icu, where the patient transferred to..."

The pharmacist then responded, "...Do you

remember did you have to wait for him to come
pick it up?..." The pharmacy tech then responded,
"...Yes. But the RN in the ED said she wasn't going

to give it right away cause of change of shift..."

State Form XGN311 IF CONTINUATION SHEET Page 32 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0940 Continued from page 32 P 0940

Interview on July 5, 2017 at approximately 11:55

am with EMP4 and EMP5 confirmed that the

pharmacist verified the order at 0649, but that there

was no documentation of when the medication left

the pharmacy.

Interview on July 6, 2017 at approximately 10:00

am with EMP16 confirmed that they did not give the
Kcentra in the ED. Further interview with EMP16
revealed that when DOH asked if they told the
pharmacy not to send it due to change of shift, they
responded, "I don't recall saying no, don't bring it."

State Form XGN311 IF CONTINUATION SHEET Page 33 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 0940 Continued from page 33 P 0940

P 1324 P 1324

State Form XGN311 IF CONTINUATION SHEET Page 34 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1324 Continued from page 34 P 1324

113.23 (a) RECORDS Completion

1. By August 25, 2017, the Penn Date:
113.23 Records State Health Milton S. Hershey 08/25/2017
(a) All drug transactions of the
Medical Center (HMC) medication Status:
pharmacy shall be recorded, and
safety and compliance pharmacist APPROVED
those records shall be correlated will modify the Factor Dispensing Date:
with other hospital records. Such
Accountability form and review with 08/24/2017
special records as are required by all HMC inpatient pharmacists and
the provisions of Chapter 25 of technicians, via email and staff
this title shall also be kept. meetings, the need to accurately
complete the Factor Dispensing
This REGULATION is not met as evidenced by:
Accountability form for blood factor
medication (including Kcentra). This
form documents the time the
medication is received on the unit
and ensures documentation of
transactions from the pharmacy to
the nursing units.

2. By August 25, 2017, the

medication safety and compliance

pharmacist will initiate an audit of

30 random Factor Dispensing

Accountability forms per month, for

two months, to ensure compliance of

recording Factor drug transactions.

The medication safety and compliance

pharmacist will address any instances

of non-compliance through the

progressive discipline

State Form XGN311 IF CONTINUATION SHEET Page 35 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1324 Continued from page 35 P 1324

process.

State Form XGN311 IF CONTINUATION SHEET Page 36 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1324 Continued from page 36 P 1324

Based on review of the medical record (MR),

facility documents and staff interview (EMP), it was

determined the pharmacy failed to ensure that all

drug transactions of the pharmacy were recorded
for one of one occurrence.

A review on July 6, 2017 of MR2 revealed that

Kcentra (for urgent reversal of acquired coagulation

factor deficiency induced by Vitamin K antagonist,

eg. Warfarin, therapy in adult patients with acute

major bleeding) was ordered STAT in the ED at

0547, was confirmed by pharmacy at 0649, but
was not given until 0836, after the patient was
transferred to the ICU. Upon admission to the ICU,

the patient's condition worsened. A head CT

showed increase in size of SDH (subdural
hematoma). The patient later died from their SDH.
Further review of MR2 revealed a nursing note from
an ED nurse, dated 6/22/2017 at 0633, "...awaiting
kcentra to be sent from the pharmacy at this time..."

Further review of MR2 revealed a nursing note from

the ED nurse, dated 6/22/2017 at 0654, "...Spoke

State Form XGN311 IF CONTINUATION SHEET Page 37 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1324 Continued from page 37 P 1324

with [name redacted] in pharmacy regarding

prothrombin complex, asked that they call when it is

avail for pick up..."

A review on July 6, 2017 of MR2 revealed a
nursing note from the neuro icu nurse, dated,
6/22/2017 at 0745, "RN called pharmacy for the
Kcentra dose ordered at 0600 that was not given in
the ER, Pharmacy brought med to the room and this

RN administered per orders."

A review on July 6, 2017 of facility policy, "
Inpatient Drug Distribution: Medication Order Turn

Around Times, " last reviewed February 2017,

revealed, " ...Procedure 1. Clear, complete, and
concise medication orders designated as " STAT "
shall be delivered to the patient care unit within 30

minutes of receipt in the pharmacy... "

Interview on July 5, 2017 at approximately 11:55

am with EMP4 and EMP5 confirmed that the

pharmacist verified the order at 0649, but that there

was no documentation of when the medication left

the pharmacy.

State Form XGN311 IF CONTINUATION SHEET Page 38 of 39

 PRINTED: 9/29/2017
FORM APPROVED
Pennsylvania Department of Health

STATEMENT OF DEFICIENCIES AND (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION: (X3) DATE SURVEY
PLAN OF CORRECTION (POC) IDENTIFICATION NUMBER: COMPLETED:
A. BLDG: __00______________

390256 B. WING: ________________ 08/02/2017

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE:

MILTON S. HERSHEY MEDICAL CENTER, THE 500 UNIVERSITY DRIVE
P.O. BOX 850
STATE LICENSE NUMBER: 135101 HERSHEY, PA 17033

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY ID PROVIDER'S PLAN OF CORRECTION (EACH (X5)
PREFIX MUST BE PRECEEDED BY FULL REGULATORY OR LSC PREFIX TAG CORRECTIVE ACTION SHOULD BE COMPLETE
TAG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

P 1324 Continued from page 38 P 1324

State Form XGN311 IF CONTINUATION SHEET Page 39 of 39

 Certified End Page

MILTON S. HERSHEY MEDICAL CENTER, THE

STATE LICENSE NUMBER: 135101
SURVEY EXIT DATE: 08/02/2017

I Certify This Document to be a True and Correct Statement of Deficiencies and

Approved Facility Plan of Correction for the Above-Identified Facility Survey

Shannon M. Baker Rachel L. Levine, MD

Acting Deputy Secretary for Quality Assurance Acting Secretary of Health

THIS IS A CERTIFICATION PAGE

PLEASE DO NOT DETACH

THIS PAGE IS NOW PART OF THIS SURVEY