1. Joe Paparo
Dr. Warner-Meron
IHS 495
1/30/15
DOH Deficiency Report Findings/Solutions
Mercy Fitzgerald Hospital, Darby, PA
A fairly common deficiency trend over the last five years at Mercy Fitzgerald was a
series of failures to obtain physician orders before using restraints on patients. According to
policy 482.13 (e), in order to provide the proper standard of care, a physician’s order must be
documented before a patient can be placed in any type of physical restraints. A patient may be
put in restraints if they exhibit violent behavior or are deemed a risk in some way to themselves
or to others. This policy allows a check and balance to ensure that someone isn’t restrained
arbitrarily or for an unethical reason. However, this policy was violated three times between
August of 2009 and June of 2011, and is perhaps one of the most important violations Mercy has
been dealing with in the last five years because it affects the overall well-being of patients as
well as staff, and can result in highly unethical treatment and lack of respect for humanity.
The constant plan of correction by the facility, following all of these violations, was to
have an in-service to educate their medical staffs on the proper procedure to follow before using
restraints on a patient. The hope seems to be that a general reminder that a doctor’s order must be
given before restraints can be used will somehow eliminate the problem; yet this was perhaps the
most constant trend at Mercy Fitz in the past five years despite the continued education. It can
then be inferred that ignorance of the proper procedure is not the root cause of the un-ordered use
of restraints.

2. There are several other issues that could be addressed in order to help eliminate this
problem. First, there may have been a general lack of staffing in the areas of the hospitals in
which the restraints were used. If there were more doctors available at the time of crisis, perhaps
a physician order would have been easier to obtain, and the right procedure would have been
followed. It could have been a lack of access issue. Also, if there had been more staff on call
during these debacles, they could have not only worked together to help calm the patient, but
they could have also reminded each other that before restraints could be used, they needed a
doctor’s order; in a way “checking” each other. Another root cause of this violation could be the
general lack of security at Mercy Fitz; as America became aware of by the shooting that took
place at the facility last year. Perhaps security could have been called, if the floor was under-
staffed, to help get the patient under control. Finally, improving staff access to proper sedative
medications may also help cut down on violations. If the staff had better access to other means to
calm the patient, like a non-invasive sedative drug, they may have been able to relax them until
an order for restraints could be obtained. The reason that a staff may act hastily and put restraints
on a patient before an order has been documented may be because they feel they have no other
option, or their life is in danger. The best way to fix this is to provide the staff with help, either in
the form of more people or technologies, but the violation most likely came from a feeling of
helplessness.
Another less obvious trend that occurred at Mercy Fitz in the past five years could be
identified as general carelessness in certain areas. There were several violations for failure to
follow certain protocols and hospital policies and plans of action, that could be easily corrected,
but the mistakes were unacceptable. For example, Mercy Fitz created a tissue committee to meet
on a monthly basis to discuss surgeries, patients, and other procedures involving bodily tissue.

3. This committee failed to meet nine times between 2007 and 2009. In another example, one staff
failed to ensure a patient’s face was completely dry of an alcoholic type of anesthesia product
before their surgery in which the team was using an electric form of technology; if it were used
on the patient, it could have incinerated their face or even the whole building. Violations like
this, along with other maintenance and sanitation issues cannot be fixed with an in-service and a
screwdriver. They require leadership so that someone may be held accountable for these errors
that could cause infection or death. Leadership must determine that a staff may need more
assistance, or a better supervisor; because these problems create a cycle. If a facility lacks
leadership, it will crumble, and then nobody will be drawn to be employed by the hospital, which
may improve it. No one is being held accountable.
Bryn Mawr Extended Care Center
The most common trend at Bryn Mawr Extended Care in the last five years has been
violation 483.25- the failure to provide the highest well being of patients. Bryn Mawr violated
this policy eight times in the duration of the five years this report covers. Additionally, there was
also a report of sexual abuse at the facility in late 2013. The majority of the violations came out
of failures which resulted in some sort of harm to patients. A few examples of these violations
were incorrect documentation which lead to wrong drug regimens, failure to provide physical
therapy, and poor evaluation and documentation leading to hospital visits and infection. Possibly
the worst case of failure to maintain well being of a patient was one instance in which one
resident’s roommate passed away, and was left in their bed for the next five hours. The resident,
being older and less ambulatory, had no other choice but to lie there in his bed next to the bed
containing the corpse. As a result the resident suffered significant psychological burden.

4. Furthermore, the plan of correction to fix all of these problems was relatively similar. The
first aspect of correction was to address the problem that was the result of the violation. For
example, the resident mentioned above received the proper psychological counseling they
needed as a result of their dead roommate being left in the room for so long. The next step in the
correction process was, once again, informing the staff on the proper way to follow the protocols
they made mistakes doing. The problem that arises when looking at what kinds of errors were
made is these mistakes were not in the failure to follow protocol, but in the way the protocol was
followed.
In addition to the general lack of accountability that some of these more run down
facilities experience, there are several other root causes of these problems. The most significant
one may be general understaffing. Many of these violations were a result of something not being
documented properly, and in turn, someone suffered. This may have been because the staff has
too much to do, and not enough help to do it. If more staff were hired, then more responsibilities
could be evenly delegated throughout the facility, and when people have less to do, they can
focus on doing a few things well, instead of a ton of things with mediocrity. Sometimes people
are forced to rush because of job-related pressure, so cutting down on that would possibly
improve some issues. Another issue that could be improved is lack of general organization. If the
staff had been more organized as far as their priorities and their task completion, the likelihood
that resident would have remained in that bed for a prolonged period of time would be far less.
Finally, the sanitation issues at Bryn Mawr, as shown in these reports, were atrocious.
The lack of routine maintenance and cleanliness is out of control. There were several reports of
pest control problems, hazardous living conditions, and even one mention of feces left in a
shower for an extended time. This again goes back to the lack of accountability and leadership in

5. a facility. The number of complaints in the course of the five years this report covers would
surprise anyone, leaving the question of how this establishment is still in business. There is a
clear lack of initiative here, and the root cause could be deep. It could be another sort of cycle.
Someone gets a job at a crap facility, without proper supervision, and then they may do just what
they need to keep their check, no more. There is no initiative to do good work, because there is a
lack of accountability, and then people suffer, and one day someone is going to end up dead,
Bryn Mawr will have a serious lawsuit on their hands, and close.