Thursday, November 16, 2017

Philadelphia Nursing Home Cited for Violations

By Walter F. Roche Jr.

A disabled and delusional  patient at a city owned nursing home was allowed to sign herself out on multiple occasions including several in which she suffered multiple injuries while wandering city streets, according to a report by state health officials.
The report on the Philadelphia Nursing Home also cited the home for multiple violations of state and federal regulations some of which led to the injury of patients.
Surveyors from the state Health Department visited the facility to determine if it met the minimum standards for participation in the Medicare and Medicaid program. They concluded that it didn't.
The Medicare program gives the home a two-star or blow average rating in the inspection and quality categories. It is licensed for 402 beds and is run by Fairmount Long Term Care under a $35.7 million contract with the city.
The city is currently accepting proposals for a new contract.
In response to the report,  Fairmount filed a plan of correction detailing steps it has promised to take to ensure the violations are eliminated and not repeated. The home can remain in the Medicare and Medicaid programs as long as those corrections are implemented. 
According to the report, the patient confined to a wheelchair was allowed to sign herself out despite the fact that there was no authorization by a physician stating she was capable of taking care of herself,
Stating that the woman had "an extensive history of delusions" the report states that she had asserted that she had been shot in the head by her sister and that her granddaughter lived in a morgue.
The inspectors found that the same resident was found passed out in her wheelchair in a nearby neighborhood. On another excursion she ended up being treated in a hospital emergency room.
"The facility failed to the safety of one resident by failing to provide adequate supervision to prevent accidents," the report states.
Other violations cited in the lengthy report include leaving medicine carts unlocked and unattended in an area where patients had access.
Another severely impaired patient was injured when an an aide attempted to lift him without assistance and the patient landed on the floor. The patient required two staffers for safe movement, according to the report.
In yet another case the facility was cited for failing to fully investigate the cause when a patient was observed to have suffered five bruises on the return from a doctor's visit.
Also when the inspectors looked at the treatment notes left by a psychiatrist treating home patients, they found them to be completely illegible. Nursing home staffers were also unable to decipher the notes, the report states.
The home "failed to maintain complete and accurate clinical records," the inspectors wrote.
The inspectors observed the care being provided to a patient who was on isolation due to clostridium difficile and concluded proper procedures were nor being followed by nursing home personnel.
Unsanitary conditions were cited in food handling areas and food being stored was not dated to ensure it had not passed expiration dates.
In its plan of correction Fairmount said it revised procedures to be followed when a patient leaves the facility against medical advice and changed the type of lift to be used for the bedridden patient. The plan includes changes to address sanitation issues and provide for the dating of all stored foods.

Missing Vet Located

An elderly patient at the Veterans Administration has been located and is under care, according to a spokeswoman for the agency.
The patient, who suffers from severe dementia, had gone missing Wednesday and officials feared for his safety due to worsening weather.
According to the spokeswoman the 71-year-old was located following a series of tips provided by local residents. He apparently wandered away from a VA clinic where he was getting care.

Wednesday, November 15, 2017

VA Dementia Patient Gone Missing

A 71-year-old patient at a Veterans Administration facility in Pittsburgh has gone missing and an  alarm has been sounded because he suffers from severe dementia.
According to a VA spokeswoman the patient left a clinic in the city's Oakland section at 4:35 p.m. today and, despite a search of the area, could not be located. She identified the patient as George Warheit.
He is 5'8'' and weighs 140 pounds. He is wearing large glasses and has grey hair and a moustache.
Spokeswoman Kathleen Pomorski said concern has been heightened due to falling temperatures and rain.
She said anyone with information about the patient's whereabouts should contact VA Police at 412-360-6911.
He was wearing dungarees, a brown coat and black boots.
The VA spokeswoman said information provided following a public appeal which produce muliple tips now being pursued by law enforcement and other agencies.

Available photographs of Mr. Warheit are copied below. The second, clearer photo shows a younger Mr. Warheit. He now has gray hair and a gray moustache.


Friday, November 10, 2017

Hospital Cited for Widespread Bug Infestation

By Walter F. Roche Jr.

A major Pennsylvania health facility has been cited for failing to prevent a widespread infestation of bugs, mice and other pests with sightings in patient rooms, treatment areas and even an intensive care unit.
In a 34-page report recently made public, state health inspectors cited the Crozer-Chester Medical Center in Chester, Pa. for multiple violations of state and federal standards including infection control and environmental services.
According to the report the medical center's own records showed 226 reports of pest sightings throughout the main hospital campus buildings between Jan. 1, 2017 and Aug. 30, 2017.  Pests cited included mice, bugs, gnats, roaches, hornets nests, fruit flies, bed bugs, lice and a possum.
Crozer-Chester filed a detailed plan of correction in response to the inspection which was accepted by state health officials. Hospital officials did not respond to a request for comment.
The sightings included mice and roaches observed in patient rooms. Other areas where sightings were recorded included the emergency room, a labor and delivery unit and the burn trauma center.
A review of the facility records showed that Crozer-Chester failed to conduct annual performance reviews on the private pest control contractor.
The inspectors cited an interview with one hospital employee who acknowledged that "the presence of pests throughout the facility and especially in patient care areas was not a safe or sanitary environment of care."
Inspectors found glue boards and mouse traps on the floor around heating and ventilation units and in patient rooms.
The inspection, which was categorized as "an unannounced complaint investigation began on Aug. 30 and was completed on Sept. 15.
"It was determined that the facility failed to provide adequate oversight and prevention of rodents and pests throughout the facility," the inspectors reported.
In its plan of correction hospital officials said they had set a goal for a 10 per cent reduction in sightings month over month. Special monitoring will be required in dietary areas, under the plan. In addition weekly and monthly monitoring of the private contractor's performance will be initiated.
The hospital was also faulted for failing to coordinate pest control efforts with a food service contractor. The pest log, according to the report, included 22 sightings in the dietary department between Jan. 1, 2017 and Aug. 30.
"The pests listed included mice, roaches, fruit flies and a possum," the report states.employee told inspectors
An employee told state inspectors,"Pest control is an ongoing problem in the kitchen department.
The corrective action plan submitted by Crozer-Chester includes additional training for hospital staffers and monitoring of progress by the management including the facility president.

Tuesday, November 7, 2017

VA Let Full-Code Patient Die Without CPR

By Walter F. Roche Jr.

Staff at a Veterans Administration facility in Michigan, acting on misinformation from a nurse, did not attempt to resuscitate a patient who had asked to be given full code status.
That was the conclusion of the VA's Inspector General in a 20-page report issued Tuesday. The incident occurred at a VA facility in Ann Arbor, Mich. late last year.
"We found that the staff at the system did not provide CPR to a patient with full code resuscitation status," the report states.
According to the IG, the nurse who provided the misinformation had been the subject of administrative action following incidents in 2012 and 2015. The male nurse was subsequently transferred to a position not involving direct patient care.
The nurse who was the primary staffer assigned to the patient told one fellow staffer that his patient was "Do not resuscitate." That misinformation was subsequently passed on to other members of the response team and none actually checked the patient's record to verify the information.
The nurse, the IG found, "relied on memory and did not recheck the status of the patient during the event."
Noting that the patient had a cardiac history and had an incident in the hours before his death, the report states that "it is not clear whether resuscitation efforts would have been successful if employed at the time."
The report cites a series of failures in policies and procedures at the facility that permitted the error to occur'
The IG noted that the Joint Commission, which sets standards for health care facilities, "requires that all staff involved in a patient's care and treatment be aware that the patients has an advance directive."
Also noted was the fact that the although the patient was in a unit in which patients were on electronic monitoring, he was not.
Had he been on telemetry monitoring, the report states, the cardiac arrest might have prompted other staffers to check his code status.
"At this point," the report states, "it is not clear when each of the staff became aware that the patient had stopped breathing."
Finally the report states that facility administrators had noted a potential vulnerability in their processes a year earlier but they never took corrective action.

Tuesday, October 31, 2017

Hospital Cited For CPR on DNR Patient

By Walter F. Roche Jr.

An Allegheny County hospital has been cited by the Pennsylvania health officials for initiating resuscitation on a patient who had completed an advanced directive stating his desire not to have that happen.
The incident occurred in mid-July at the 328-bed St. Clair Hospital in Pittsburgh.
According to the recently released inspection report from the state Health Department, the unnamed male patient was brought to the hospital on July 17 from a personal care home. Hospital staff later verified that he was on hospice care at that facility, according to the report.
Several hours later the patient was found unresponsive and cardio pulmonary resuscitation was initiated, inspectors reported following an Aug. 14-15 visit to the hospital.
"The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives," the report states.
The report does not include any information on the results of the resuscitation efforts.
In response to questions about the report a hospital spokesman said that the facility had self reported the incident to the state.
"St. Clair Hospital recently reported to the Pennsylvania Health Department an event in which a patient transferred from a personal care home was resuscitated despite having earlier filed a "do not resuscitate" code status," the spokesman said.
He added that a plan of correction had been filed with the state and approved. It is now being implemented, according to the statement.
The plan calls for a series of training sessions for staffers with subsequent audits to ensure that directives are being followed. The hospital will also notify operators of personal care homes and assisted living facilities that send patients to St. Clair of its policies regarding advance patient directives.
Under the plan a patient's advance care directives will be entered on his or her record upon admission.
"The appropriate code status designation will be entered into the patient's medical record upon admission," the report states.
"This event underscore St. Clair Hospital's objective to ensure accurate communication regarding patient wishes about end-of-life care," the hospital statement continued.
In addition to the failure to follow a patient's directives, St. Clair was cited for failing to administer written orders of a practitioner and failure to ensure that cardiac monitoring equipment was functioning properly. A cardiac monitor had been ordered for the patient but the first reading was recorded only after he was found unresponsive, inspectors reported.
In response St. Clair said it would implement a plan to increase cardiac monitoring and to train staff on how to use the equipment.

Sunday, October 22, 2017

Admissions Frozen at Privatized Metro Facility

By Walter F. Roche Jr.

Citing violations of state and federal laws and regulations state health officials have ordered  a freeze on admissions at the Nashville nursing home which Metro Nashville officials privatized and turned over to a private for profit company three years ago.
The order issued late last week by state Health Commissioner John Dreyzehner also imposed fines totaling $7,500 on the facility now known as Nashville Community Care and Rehabilitation at Bordeaux.
Under an agreement with Metro operation of the 419 bed was turned over to Signature Health Care, a chain of nursing homes, which has been cited by the state for deficiencies at its other facilities.
Dreyzehner said a special monitor was also appointed to oversee operations of the facility at 1414 County Hospital Road.
The freeze was imposed based on a complaint survey conducted by state health inspectors from Sept. 24 to Sept. 27.
According to the commissioner, violations uncovered related to the administration of the facility and and patient rights.
The notice, effective Oct. 19, bars the facility from admitting any new patients until further notice. The nursing home is required to post a copy of the order at its main public entrance "where it can be plainly seen."
The nursing home can appeal the findings and the two fines of $5,000 and $2,500 to a state board.
In announcing the freeze Dreyzehner cited a state law that authorizes the commissioner to suspend admissions "when conditions are determined to be, or are likely to be, detrimental to the health, safety and welfare of the residents."
Metro's agreement with Signature privatizing the Bordeaux facility has not been without controversy in part based on the amount of money the city is committed to provide to help underwrite its losses.
The initial lease was signed in 2014 and was renewed for another four years in 2016.
Another Signature facility, Signature Health Care at Saint Francis in Memphis was cited by the state in March for multiple violations of state and federal regulations. As a result the nursing home had its Medicare agreement terminated and the agency ceased any further payments.