By Walter F. Roche Jr.
The Philadelphia nursing home now under investigation in the suspicious death of s high profile patient has been cited in the past for of providing poor care to a patient.
Last year the nursing home at Cathedral Village was cited by state health inspectors for failure to follow a physician's orders in providing care to a male patient recovering from hip surgery.
According to the surveyor's report, the patient's dressing was saturated with blood "and the yellow and brown colored drainage.
The nursing home portion of Cathedral Village, known as Bishop White Lodge, is under investigation by Philadelphia Police who have classified the death of Herbert McMaster as suspicious. A department spokesman confirmed the investigation is ongoing. McMaster was the father of H.R. McMaster, the former National Security Advisor to President Trump.
He reportedly was admitted following a recent stroke and apparently died after suffering a fall while at the Andorra health care facility
A state Health Department spokesman said the agency was aware of the investigation and was in the process of conducting an investigation in the form of a facility survey. Stating that the department cannot comment on an ongoing investigation, the spokesman said that the results of that survey would eventually be made public.
The Aug. 22 state survey cited the facility for failure to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being" of the patient.
The state inspector wrote,"The dressing was completely saturated with a heavy amount of blood, including a heavy amount of yellow and brown colored drainage."
The patient pointed out to the inspector that the bedsheets were also covered with blood and drainage from the patient's incision.
The report also notes that the dressing did not include a notation of the date and time it had last been changed, which was required under the nursing home's policies.
According to the report the patient had been constantly telling staff that the dressing needed to be changed.
An employee acknowledged to inspectors that the doctor's orders for the changing of the dressing had not been followed.
State inspection records show that in a subsequent visit, inspectors found that the nursing home had corrected the cited deficiencies.
The department made two other recent visits to the home in response to complaints but did not find any deficiencies.
Monday, April 16, 2018
By Walter F. Roche Jr.
A monitor technician at a Philadelphia hospital turned off a cardiac monitor alarm and the patient was found dead about 20 minutes later during a routine check by a nurse, according to a report by the Pennsylvania Department of Health.
The report on the Nazareth Hospital in Northeast Philadelphia cited the facility for "failure to ensure the well being of the patient by failing to respond to a cardiac monitor alarm as per facility policy."
According to the inspection report, a monitor technician on duty on Dec. 7 of last year "did not correctly identify a change" and silenced the alarm without verifying the rhythm or notifying the nursing staff of the alarm.
Nazareth, part of the Mercy Health System declined, to answer a series of questions about the incident but issued a brief statement.
"The safety of our patients is our top priority, and we maintain strict procedures to promote a positive, healing environment and to ensure patient confidentiality," Christy McCabe wrote in an email response to questions.
"We work closely with the Pennsylvania Department of Health and other regulators to ensure we continually implement best practices for patient safety," the statement concluded.
McCabe did not respond to questions including whether any action was taken against the technician or whether the new telemetry equipment has been put into use.
Nazareth, a 200-bed hospital, did file a plan of correction with the state in which they promised to re-educate technician monitors. They also said those technicians were tested by a Feb. 28 deadline.
Nazareth also said it would install new telemetry equipment to help ensure the incident would not be repeated.
State inspectors, who visited Nazareth on Feb. 26 through Feb. 28, said records showed that by the time the nurse who found the patient called a code blue, more than 20 minutes had passed since the alarm sounded.
The patient could not be revived. The incident occurred late in the afternoon of Dec. 7.
The inspection report states that Nazareth failed to maintain good quality care and high professional standards by not following established cardiac monitors policies."
Monday, April 9, 2018
By Walter F. Roche Jr.
For the second time this year Temple University Hospital has been cited by state health officials for issues at its behavioral unit at the so-called Episcopal campus.
In a 12-page report made public last week, the Pennsylvania Health Department said the facility failed to file a required report following an accusation of patient-on-patient abuse. The finding followed a two day review in February of the facility records.
"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," the report states, adding that the state was not notified of a complaint of "patient-on-patient abuse."
The incident, the report states, occurred on Sept. 2 of last year when a patient reported to a staff nurse that a male patient had kissed her causing her to become upset.
The patient who filed the complaint also attempted to confront the male patient stating "I'm going to kick your a.."
The inspectors wrote that the patient had to be separated from the male patient and was redirected to her room and was given medication due to her agitation.
Temple was cited for failing to provide a safe environment "free from any form of abuse, harassment, exploitation and neglect."
Despite the incident, the inspectors said Temple failed to comply with a requirement to report complaints of abuse to the state agency.
Temple filed a plan of correction in which they promised to educate staff on reporting requirements and to monitor to ensure compliance.
"Education began in March to remind staff to report all patient/family reports of abuse," the plan states.
In the same report, Temple was faulted for failing to take action after the patient who filed the abuse report was described at the time of admission as "disheveled and malodorous."
The report states that despite that observation hospital records "did not contain documented evidence of any assistance provided to the patients for completion of the activities of daily living by nursing staff during the patient's entire admission."
The citation is the second this year for the Temple 198-bed behavioral unit. An earlier report cited the facility for overuse of restraints.
Temple Hospital officials did not immediately respond to requests for comment
By Walter F. Roche Jr.
Tennessee health officials have ordered a halt to any new admissions and imposed fines following inspections showing evidence of patient abuse, including slapping patients, withholding liquids along with verbal and mental abuse.
Ordered to halt any new admissions were Diversicare of Claiborne and Brookhaven Manor of Kingsport.
A 33-page report on the Claiborne facility cited repeated abuse of some patients by a licensed practical nurse. A certified nursing assistant was cited for slapping a patient.
At the Kingsport facility, state surveyors found that a patient who had violated smoking rules, was ordered out of the facility and taken to a local hotel with just three nights paid for.
The report charges that Brookhaven "placed a resident in an environment that was detrimental to his health. Although the resident had appealed his discharge, he was discharged without his medications for multiple illnesses.
The home was cited for failing to transfer the unnamed resident "to the most appropriate facility or setting to meet his or her need in terms of quality services and location."
A $12,000 fine was imposed against Brookhavem while a $20,000 fine was set for Diversicare.
Wednesday, March 28, 2018
By Walter F. Roche Jr.
The Temple University Hospital placed patients in the most restrictive of restraints without proper justification, according to an inspection report from the Pennsylvania Health Department.
In a 40-page report just recently made public, surveyors from the state health agency found that staffers at Temple's Episcopal campus "failed to ensure that alternatives to restraints were utilized and proven to be ineffective prior to the application of restraints."
Instead, when state inspectors visited the 198-bed behavioral health facility late last year, they found several patients had been placed in four point restraints, the most restrictive available, without considering less restrictive alternatives.
In addition the report states staffers at the facility failed to remove those restraints in a timely manner and also failed to monitor patients while they were in those restraints.
Asked to comment on the report, Temple spokesmam Jeremy Walter said that the inspectors visited the Episcopal campus as a result of an anonymous complaint.
Although the complaint proved to be unfounded, the inspectors found other issues, Walter said. Stating that those issues were "quickly remedied," he added that "there were no untoward patient outcomes."
Temple also filed a corrective action plan in which it promised to revise policies for the use of restraints,implement an auditing program to ensure it is being followed and educate staff. State officials accepted that plan.
According to the inspection report, the state surveyors found that on Dec. 2 of last year two patients were placed in four point restraints but "there was no evidence" that less restrictive alternatives were considered.
The same was true, according to the report for three other patients placed in four point restraints later in the same month.
In one of those cases, the report states, there was no indication that there was an effort to discontinue the restraints at the "earliest possible time."
Another patient remained in restraints even though he or she was cooperative and had slept for two hours. In yet another case, surveyors found that there was no evidence of compliance with a requirement that there be constant monitoring of patients while being held in restraints.
The facility also was faulted for referring victims of sexual assault to another facility when they were required "at a minimum" to perform a forensic exam and utilize a rape kit.
Tuesday, March 27, 2018
By Walter F. Roche Jr.
The burn treatment unit at a Delaware County hospital that bills itself as "a national leader in burn care,"has been cited by state inspectors for failing to follow required infection control practices, including compliance with basic hand hygiene.
In a 39-page report recently made public, the state Health Department also found that for years the hospital has been using the wrong liquid to flush hoses used in the treatment of burn patients.
Since 2006, the report states, hospital staffers have been using chlorhexidine instead of bleach to flush hoses in the hydro therapy room.
Although staffers were required to immediately decontaminate their hands after removing gloves between patient contacts, the state surveyors found that practice was not always followed.
"I witnessed a physician scratch his nose and scalp, put on personal protective equipment and then enter a patient's room," a hospital employee wrote in an email exchange.
The same employee, who was conducting a hygiene compliance audit, wrote that when two residents attempted to follow the doctor into the same patient's room wearing only a gown "I asked them to wash their hands prior to entry and they stated, 'We never had to wash our hands before,'"
Andrew Bastin, a Crozer spokesman, said the facility would be filing a corrective action plan by the April 1 deadline.
"Crozer-Keystone Health System is committed to providing exceptional care with an emphasis on patient safety. Routine inspections from the Pennsylvania Department of Health are a valuable way to identify opportunities for continued improvement," he wrote in an email.
In their report, the state surveyors noted that despite prior internal findings that the expected 100 percent compliance with hand hygiene practices was not being achieved, no action was taken by patient safety and a local governing body.
quality panels established to ensure standards were being met.
"There was no documentation of any actions taken by the local governing body with regard to the staff's failure to meet the benchmark for hand hygiene compliance of 100 per cent," the report states.
In fact the hospital's own audit records showed the hand hygiene compliance rate declined from October of 2016 to October of 2017.
As for the hospital's governing body, the report states that the panel "failed to ensure that the patient's right to care in safe environment was maintained."
Friday, March 23, 2018
By Walter F. Roche Jr.
Tennessee health officials have ordered a Washington County nursing home to cease admitting any new patients after state inspectors found multiple violations at the facility.
The order and fines totaling $6,000 against the Family Ministries John M. Reed Center in Limestone were announced today by state Health Commissioner John Dreyzehner. The facility is licensed for 63 beds.
The commissioner said the violations were uncovered in three areas; nursing services, medical records and pharmaceutical services.
In addition he said a state monitor has been appointed to oversee operations at the home.