Friday, September 15, 2017

Nursing Home Fined; Admissions Barred

By Walter F. Roche Jr.

A Nashville nursing home has been fined $15,000 and barred from admitting any new patients after an inspection showed multiple violations of state and federal laws and regulations.
Records show that dozens of patients of the facility needing critical maintenance medication went multiple times without getting doses of drugs for diabetes, hypertension and convulsions.
The fine  and admissions freeze was imposed on the  Nashville Metro Care and Rehabilitation, formerly know as Crestview Health and Rehabilitation, located at 2030 25th Ave. in Nashville.
The action was announced by Tennessee Health Commissioner John Dreyzehner. The nursing home has 111 licensed beds. The suspension followed an on-site inspection from Aug. 21-28.
Dreyzehner said a special monitor has been appointed to oversee the operation of the facility in the interim.
The state inspectors found violations in three general areas; physician services, nursing services and medication administration.
The 65-page inspection report cited multiple sanitation and maintenance problems including  pervasive urine smells.
One nursing home worker told an inspector, "The urine smell is between (room) 204 and 205. It's not as strong as it usually is."
The report shows the home had long term staffing problems and at times only a single registered nurse was on duty for an entire shift. It often relied on staffing agencies, but home administrators could not produce a contract with those agencies.
The staffing shortage, inspectors found, led to multiple missed medications for dozens of patients on life sustaining drugs.
When a nursing home administrator was asked about the persistent staff shortage, the response was, "I feel like you caught me with my pants down."
The report cites the home for failure to respond when an unattended patient fell out of bed. The patient's hip fracture was not detected until several days later. According to the report the facility failed to notify the patient's doctor or his legal representative.
The nursing home employee who discovered the patient on the floor told inspectors she didn't know how to enter the incident into the computer system.

Wednesday, September 13, 2017

UPMC Hospital Cited for Improperly Filming Patient

By Walter F. Roche Jr.

In what one participant described as a "circus," physicians and other employees of a Bedford County hospital crowded into an operating room late last year to observe and take pictures and videos of an unidentified patient being treated for a genital injury.
The group, which included several employees not involved in the treatment of the patient, took pictures and videos on their personal cell phones of the patient who had not given consent, all in violation of official hospital policy.
The Dec. 23, 2016 incident was investigated by the Pennsylvania Health Department and resulted in a 41-page report which concluded that the UPMC Bedford Memorial Hospital "failed to protect the personal privacy, dignity and respect of the patient."
The 59-bed hospital in Everett, PA is part of the UPMC system. UPMC officials did not respond to a request for comment.
The hospital filed a plan of correction in which officials promised to initiate policy changes to prevent a recurrence. They also reported that physicians and employees involved were suspended for periods of up to 28 days.
The incident came to light when a hospital employee "came forward to complain about photographs that were circulating around the hospital of a patient under anesthesia while in the operating room."
The inspection report, which was recently made public, does not provide complete details on the patient's genital injury, but does state that the surgery involved the removal of a foreign body.
One hospital employee told state investigators, "I was curious. I couldn't imagine how the patient did it," adding, "There was quite a crowd"in the operating room.
"We never had a circus like this before," an employee told investigators.
The report was the result of an on site investigation from May 23 of this year to June 9.
According to the report, in addition to violating the patient's privacy rights, the incident violated a variety of hospital rules, including a requirement that only approved hospital equipment could be used to take photos of patients.
The state investigators also gathered evidence that the Dec. 23, 2016 incident was not the first time patients had been photographed without consent.
"Generally we don't tell that to a patient," one employee told investigators. "It was a medical curiosity," the employee continued. "We are a small hospital. It is commonplace for everyone to know what cases are coming in."
Another employee told state investigators, "I do take pictures of genito-urinary anomalies for educational purposes."
The employee said he did warn colleagues stating, "Stop this is a HIPPA (Health Insurance Portability and Accountability Act) violation," adding that he told the curious employees they could return to the operating room once the patient was anesthetized.
According to the report, a surgeon said before the surgery finally began, "That's enough. We've got to get going."
Another employee stated that at one point, some onlookers were asked to leave "because they did not have enough eye protection for everyone due to the sparks flying from the tools that were being used."
The 2016 incident came more than two years after the disclosure that a physician took a selfie with comedian Joan Rivers, during the surgery that ended her life.

Friday, August 18, 2017

Hershey Hospital Cited in Death of Six-Year Old

By Walter F. Roche Jr.

A Hershey hospital has been cited by Pennsylvania health officials for failing to report the unexpected death of a six-year-old boy and failure to follow expected standards of care in treating him.
According to a lengthy state inspection report, the Milton S. Hershey Medical Center only notified the Pennsylvania Health Department of the death after an anonymous informant had reported the Jan. 11 death months after it occurred. Under state law and regulations the death should have been reported within 24 hours of its occurrence.
In response to questions about the citation, the medical center issued a statement acknowledging the delay in reporting the incident and also the fact that there was a 10 hour gap in the recording of the patient's temperature.
"The facility failed to meet the emergency needs of a patient with acceptable standards of practice," the inspection report states.
The boy, who was brought to the hospital's emergency room on Jan. 10, was placed in a warming device due to a low temperature. He had a temperature of 107.6 degrees when he was found unresponsive the next day.
"There were no vitals,"the inspection report states, adding that hospital staffers acknowledged the warming device, called a Bair Hugger," had been on high all night.
He was pronounced dead at 5:39 p.m. on Jan. 11.
In addition to the failure to report the death, the hospital was cited for failing to adequately train employees and failing to follow the warming device manufacturer's guidelines calling for temperature checks every 10 to 20 minutes.
In its statement, the medical center said management did not become aware of the incident until notified by the state following the anonymous complaint to the state Patient Safety Authority.
"This situation raised serious issues, and our response has been equally serious" the hospital said in its statement.
Acknowledging that the state found a total of five violations, the medical center
termed the incident an "unacceptable failure" and said corrective action was initiated  as soon as it received notice of the anonymous complaint.
 The state sent inspectors to the hospital on April 12 and they completed their review the next day. Because the inspectors declared a state of "immediate jeopardy," the hospital was required to respond immediately with a corrective action plan. The "immediate jeopardy" was lifted on April 13.
In its statement the hospital said the boy was suffering from "ongoing, complex and life limiting health issues" and "presumed sepsis" when he was brought to the emergency room in January.
After he was found unresponsive the next day, he was taken to the the hospital's pediatric intensive care unit but died later in the day.
The hospital said its own investigation found "an agency nurse was overseeing the child's care during the 10-hour gap in temperature documentation, and no one involved in the child's care reported the incident to our Patient Safety Department."
In its inspection report, the state said that the nurse in question said she knew she took the patient's temperature but forgot to document it.
"I did not have the computer with me. I was probably busy with something else," she told the inspectors.
The state found that although the nurse had been hired a year earlier, there were no evaluations in her file and core competency for use of the warming device "was not completed."
According to the hospital statement, the facility now limits the use of the warming devices to operating rooms "where patients are continuously attended."
Other steps include training for staffers, including those hired through an agency, on the use of such devices and audits to ensure serious incidents are properly reported.
"As an organization that holds itself accountable for providing the highest quality care while protecting the safety of patients, employees and visitors, we recognize this situation was an unacceptable failure," the hospital said in its statement.

Tuesday, August 15, 2017

Philly Hospital Cited in 4 Patient Deaths

By Walter F. Roche Jr.

A major Philadelphia hospital has been cited by state health regulators for failure to fully investigate the cause of four unexpected patient deaths in 2016, refusing to provide official records and refusing to allow state surveyors to interview key staffers involved in the incidents.
In a report recently posted on its web page, the Pennsylvania Health Department cited the 701 bed  Albert Einstein Medical Center for failure to comply with state and federal requirements in serious cases "involving the clinical care of a patient that results in death or compromises patient safety."
The report was the result of a site visit to the Einstein facility described as an unannounced complaint investigation in early May.
Einstein officials filed a plan of correction in which they promised to institute new patient safety protocols and to use those new standards for all serious events beginning on July 1.
The hospital, however, repeated the assertion that some of the records sought by state inspectors at the time of the inspection are "peer review, protected, privileged documents, entitled to protection under federal and state law."
Einstein officials did not respond to a request for comment.
In the first case cited a deceased patient who had been admitted in late July of 2016 was found looking pale and unresponsive on Aug. 7, 2016. Records examined by the surveyors attributed the death to "excessive sedative use leading to hypo-ventilation and brain anoxia."
In a second case an unidentified patient underwent a colonoscopy on Sept. 23, 2016 and returned "with worsening abdominal pain."
The patient had elected to leave after the procedure "against medical advice," the report states.
The patient, who had apparently suffered a colon rupture, did not survive.
In another case a patient reported to the emergency room on June 21, 2016 with "agitation and psychiatric symptoms."
The patient asked for something to eat and was given a sandwich. The nurse returned to find the patient choking. The patient subsequently expired.
State inspectors asked for records showing required reviews were performed following the death. "None were provided," the inspection report states.
Another death occurred following an esophageal intubation in February. When state surveyors asked for documentation and the results of a "root cause analysis," they were told the documents were confidential and "protected."
In addition, the report states, that no completion dates were included for "action items" set to be implemented as a result of the incidents.
Cited in the report was a requirement by licensed health facilities to "track medical errors and adverse patient events, analyze their causes and implement preventive actions and mechanisms."

Wednesday, April 13, 2016

Icing, Loss of Engine Cited in Fatal Nashville Plane Crash

By Walter F. Roche Jr.

A 2014 Nashville, Tenn. plane crash that took the lives of four members of a Kansas family was caused by the failure of the pilot to maintain airspeed after an engine failed on his third attempt to land the Gulfstream turboprop in icy conditions.
The fiery Feb. 3 crash killed Glenn Mull, 62, his wife Elaine, 63, and a child and grandchild of the couple.
In a lengthy and detailed report issued last month, investigators for the National Transportation Safety Board said that due to extensive damage they were unable to determine the cause of the engine failure, which apparently caused the aircraft to veer to the left.
A contributing factor, according to the report was ice accumulation "due to conditions conducive to icing."
The NTSB found that there were several reports of aircraft icing problem around the time of the crash although it was unclear how many of those reports were relayed to Glenn Mull, who was piloting the plane, owned by his cattle raising company, Mid-Kansas Agri Co.
The report describes in detail the anti-icing and de-icing equipment on the aircraft including a warning from a manufacturer that the system had to be activated before ice began to form.
"Warning: When icing conditions may be encountered, do not delay operation of the engine inlet heat systems. Turn the systems on before any ice accumulates. Engine inlet heat must be on if icing conditions exist or are anticipated," the NTSB report states, citing instructions from the manufacturer.
The Mulls , their daughter Amy Harter, 40,  and 16-year-old granddaughter Samantha, died from "multiple blunt force injuries," according to an autopsy report cited by the NTSB.
The twin engine turboprop first hit trees near the Bellevue YMCA outside Nashville and then slammed into the ground creating an 11-foot by 11-foot crater six-feet deep. It was attempting to land at the John C. Tune Airport.
Mull was traveling with his family to Nashville from Great Bend , Kan. to attend an agricultural convention. According to the report, the plane, built in 1982 and purchased by Mull's company in 2000, had been serviced and inspected just prior to the flight to Tennessee.
The report provides a detailed accounting of Mull's attempts to land the plane including a conversation with traffic controllers after one failed attempt in which he said he wanted "to do it again."
According to the report, Mull, at one point,  failed to follow the heading instructions radioed to him, but traffic controllers did not correct him because the difference was not consequential.
On the third landing try, the report states, "the airplane was on the final approach course when it veered to the left and began a descent... The airplane impacted trees and a field adjacent to a building (the YMCA)."
"The type and degree of damage to the left engine," the report states, "was indicative of an engine that was not operating with rotation consistent with a wind milling propeller at the time of impact," the report states.
Following the crash Mull was credited by some with steering the plane away from the nearby YMCA, packed with children, but the NTSB report states that the descent was "uncontrolled."

Tuesday, April 12, 2016

Dead Pilot Fixated on Taylor Swift

By Walter F. Roche Jr.

The pilot who crashed his plane on a fog bound Nashville, Tenn. runway in 2013 was drunk and fixated on Taylor Swift, perhaps explaining his fatal and unauthorized flight from Canada to mid-Tennessee.
A report from the National Transportation Safety Board concludes that Michael Callan, 45, of Windsor Canada crashed his rented plane while attempting to land in dense fog.
"Contributing to the accident was the pilot’s mental state, his impairment due to alcohol, and his decision to operate the airplane from Canada to the United States without the owner’s permission and without proper clearances for the flight," the brief report concludes. 
The Oct. 29, 2013 crash occurred in the early morning, but the wreckage on a Nashville International Airport runway was not discovered till hours late.
Callan's body was found among the charred and scattered remnants of the Cessna 172R aircraft, the pilot had rented from a Windsor flying club.
"This pilot was not supposed to be in the United States flying to Tennessee," an NTSB record states.
The NTSB investigation noted that Callan had apparently circled the airport for some two hours before making his final fatal approach. He had taken off from Windsor some nine hours earlier on a flight that was supposed to end on Pelee Island on Lake Erie within the Canadian border.
Noting that Callan was not qualified to make an instrument landing, the report states, "the pilot was unaware of the IFR (instrument only) conditions in Nashville until he arrived in the area and that, because he was not instrument rated, he was unable to safely land the airplane with no visual contact with the runway."
Callan's mysterious trip drew widespread attention when officials disclosed that he had listed Taylor Swift as his emergency contact person.
Records gathered by NTSB investigators show that Callan had named Swift on his application to the Windsor Flying Club, the organization that rented him the plane. Swift has stated through her publicist that she did not know Callan.
"He (Callan) had developed a significant interest in a celebrity who lived in Nashville," the NTSB report noted, adding that he also had "a history of repeated convictions for criminal activity."
 "Although the medical records did not include a specific psychiatric diagnosis, the pilot’s prior criminal actions and impulsive behavior are consistent with antisocial personality disorder, which likely led to his impetuous decision to fly to Nashville," the NTSB states.
The report cites an August 2012 mental health evaluation of Callan in which "he reported that he had developed a significant interest in a celebrity and had written several letters to her. According to the mental health evaluator, the letters 'have the flavor of stalking.' The celebrity of interest resided in Nashville, Tennessee at the time of the accident."
"Toxicological testing of the pilot’s blood revealed significantly elevated levels of ethanol, indicating that the pilot ingested alcohol before the accident. The alcohol likely further impaired the pilot’s judgment and his ability to fly the airplane safely in IFR (instrument only) conditions," the report adds.
An autopsy conducted by Tennessee authorities following the crash found that Callan's blood alcohol level was .081 percent, over the .080 percent Tennessee legal limit to drive a car. Federal regulations set a  .04 percent limit for aircaft operators.
The NTSB examination of the wreckage "found no mechanical malfunctions or failures that would have precluded normal operation."

Thursday, April 7, 2016

Montco MH/MR Agency Cited for Overdoses

By Walter F. Roche Jr.

A Montgomery County agency providing services to the disabled has been cited by the state Health Department for dispensing methadone at  dosages of up to four times the amount prescribed by a physician.
In an inspection report recently made public, state inspectors cited two cases in which the wrong dose of methadone was dispensed to patients at Montgomery County MH/MR Emergency Services.
In one of those cases, according to the report, the patient was later discovered unresponsive, with a drastically reduced blood pressure and had to be rushed to a local hospital for emergency treatment.
Officials of the agency, located in Norristown, declined to respond to questions about the ultimate fate of the two patients.
In addition to the overdoses, state inspectors found several other violations of state and federal regulations including the presence of expired drugs and quality assurance deficiencies.
The facility failed to "properly discard expired medicines and supplies," inspectors found.
In the first of the overdoses, the report states that the patient was administered the overdose on Nov. 15 of last year at 5:50 p.m. The mistake was discovered later in the evening prompting the sounding of a crisis alarm.
After a doctor had ordered close monitoring of the patient, staffers discovered at 12:10 a.m. that he was experiencing labored breathing and his skin was discolored. After administering oxygen the patient remained unresponsive and was rushed to a local hospital.
A second patient, according to the report, who was supposed to receive a 40 milligram dose of methadone, was mistakenly given a 175 milligram dose.
Despite that discovery, the inspectors found, the patient was not administered a drug, Naxalone, to counter the effect of the overdose.
"Narcan was not administered even though Narcan was available on the code cart. Everyone is in agreement that Narcan should have been administered," the report states, citing subsequent interviews with agency personnel
Other violations cited included the apparent failure to get patients' consent prior to the administration of psychotropic drugs.
Another finding was the apparent failure to inform patients or their representatives of visitation rights. That was the case in 10 of 12 records reviewed, the report states.
In a plan of correction filed with the state, agency officials promised to implement new procedures to ensure that the proper doses of drugs were administered and steps to be taken in the event of an overdose.
They also promised to establish a monitoring procedure to avert any recurrences.
The inspection, listed as an unannounced federal complaint investigation, took place from Jan.27 to Jan. 28. The report was not made public until the county agency had the opportunity to respond.
According to its latest tax return, the Norristown agency had revenues of $17.1 million and expenses of $18.2 million in the most recent fiscal year.