Tuesday, March 20, 2018

Philadelphia Hospital Cited on Life Safety

By Walter F. Roche Jr.

A major Philadelphia hospital has been cited for multiple deficiencies following a Medicare inspection of fire protection and other building safety requirements.
The four day January review at Pennsylvania Hospital found deficiencies in several buildings including missing fireproofing on structural beams, fire alarms that were partially inoperative and exposed electrical wires.
The 520-bed hospital, part of the University of Pennsylvania Health System, was inspected from Jan. 9 to Jan. 12 for compliance with provisions of the federal Life Safety Code.
Asked for comment, a Penn Medicine spokeswoman said," We worked to correct the items in the report as quickly as possible as well as put alternative protections in place to ensure the safety of all occupants."
She said the state findings "were part of a routine regulatory inspection," adding they were "very common in an active occupied hospital building. At Penn Medicine, patient safety is our number one priority."
Other findings include the failure to maintain the fire resistance rating of common walls and or on stair tower enclosures.
On the sixth floor of one building a door failed to positively latch. In several locations the state inspectors found unsealed penetrations. At another location they found a fire alarm system component with an inoperable component.
A review of fire sprinkler systems found that some gauges had not been serviced within the five year limit. Smoke compartments in some sleeping locations exceeded the maximum area.
According to the report, structural steel in the neurosurgery building lacked fire protection.
Also cited was the fact that the control panel for a fire alarm system in one building was located in a basement under lease by another party, raising concerns about accessibility in the event of an emergency.
In a parallel Medicare review of patient care, inspectors cited the hospital for failure to dispose of expired medications.
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Wednesday, February 14, 2018

Two Suicides in Five Days at Belmont

By Walter F. Roche Jr.

Two patients at a Philadelphia behavioral hospital committed suicide in a five day period, according to a court suit and an inspection report by Pennsylvania Health Department.
The deaths on April 24 and April 29 of last year occurred at the Belmont Behavioral Hospital, part of Acadia Healthcare,  a Tennessee based company.
In the April 24 death, which was detailed in a health department inspection report, the patient hung himself in an area that was supposed to be free of fixtures that could be used for ligatures.
The April 29 death involved Jerry W. Gates, 59, a patient who was transferred to Belmont following treatment at a Chester County hospital for dizziness and reporting that "he was hearing voices telling him to harm himself."
The suit charges that despite the diagnosis Belmont determined he "presented a low risk of suicide" and suicide precautions were not provided.
The suit charges Belmont and its parent company Acadia Healthcare with negligence and wrongful death. In a 19-page answer Belmont and Acadia denied any negligence or liability.
The complaint charges that Gates was able to wander from room to room without any supervision and he was not provided with medication for his known insomnia.
 The suit adds that he was found at 4:10 a.m.lying on the floor "bleeding profusely from gaping wounds of the neck caused by a portion of a picture on the wall with which he stabbed his neck.
The suit charges that the facility lacked sufficient and appropriately trained staff.
Acadia, the complaint states, was a direct participant and exercised corporate control over Belmont.
Calling the care provided "a gross deviation from accepted standards of care," the complaint charges the defendants with "flagrant and gross negligence."
In their answer, the defendants acknowledged that Gates was found bleeding from a neck wound. but denied he was found lying on the floor or that he died on the way to a hospital.
"It is specifically denied that Gates was not supervised and was allowed to roam freely without any supervision," the answer states, adding that "all liability against defendants for wrongful death are denied."
As reported previously on this blog, a second suicide at Belmont was detailed in a state inspection report. In that case an unnamed patient hung himself. The state cited Belmont for multiple deficiencies including lack of staff and failure to have facilities designed to prevent suicides.
In fact state inspectors declared a state of imminent danger when they visit in early November of last year.
Contact: wfrochejr999@gmail.com

Monday, February 12, 2018

Philadelphia Hospital Cited In Suicide

By Walter F. Roche Jr.

A Philadelphia behavioral hospital has  been cited in the suicide death of a patient and a host of other violations of state requirements' many involved in the treatment of patients with Electro Convulsive Therapy (ECT) ,in a recently released report..
 The report on the Belmont Behavioral Hospital was first made public without an approved corrective action. The agency normally posts inspection reports only after the submission of an approved plan of correction.
"An approved plan of correction is not on file," the report stated.
 Mark Schor, a Belmont official, said the facility did submit a plan of correction and that state officials had accepted it.
The latest version of the inspection report posted today shows that several parts of the corrective action plan have been accepted while others have not.
Schor also said the hospital is in the process of building a 250-bed state-of-the-art replacement facility, scheduled to open in late 2019.
According to the report, based on a Nov. 9 visit to the hospital, inspectors declared a state of immediate jeopardy after discovering numerous violations of anti-ligature requirements, rules set to minimize the risk of suicides.
The failure to comply with those requirements "resulted in the suicide death of one patient," the report states.
The patient was pronounced dead on April 24 of last year.
"The patient was found hanging from a loopable point on a bathroom anti-ligature door," the report states, adding that in addition the hospital failed to request an autopsy report and forms on the disposition of the body were not completed.
The hospital failed to provide a safe setting, the report continues, adding that a hospital psychiatrist "did not document the observations and special precautions" needed for the patient.
The facility did immediately change its policy to require that all patients with a suicidal risk be observed by staff every seven minutes. As a result the state of immediate jeopardy declared at 12:14 p.m., on Nov. 9 of last year was lifted at 7:46 p.m.
In its corrective action plan Belmont said they had designated a patient safety officer and that policies and  procures for ECT treatment were reviewed and revised.
Belmont is part of the Acadia Health Care LLC, a company that operates some 579 treatment facilities.
Other findings by the state Health Department surveyors included the failure to properly monitor patients who had undergone ECTs. During the visit two patients were observed in the treatment area without any staff present.
Still other violations included medication carts left unlocked and unattended and failure to maintain complete records showing how many vials were used on ECT patients. There was "no documented evidence of how many vials were delivered to the ECT room," the report states.
Inspectors also cited failure to respond to grievances within a seven day limit and failure to secure patient records to ensure confidentiality. They observed 166-pages of patient related data in open view.
Inspectors also said Belmont "failed to ensure a sufficient number of nursing staff were available to meet the nursing needs of the patients."
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Friday, January 19, 2018

Einstein Inspection Report Finally Posted

By Walter F. Roche Jr.

More than six months after a critical inspection, state officials have finally made public a trimmed down hospital inspection report that omits multiple details included in a prior version which state officials now say had been briefly but mistakenly made public.
The now official report on a three day May inspection at the Albert Einstein Medical Center cites the
701 bed facility for failure to properly analyze and implement preventative actions after four patients experienced adverse events.
"The  hospital must measure, analyze and track adverse patient events," the report states.
The official report provides details on two of the cases which resulted in deaths. Details of two other deaths included in a prior version of the report are not included in the official report.
April Hutcheson, spokeswoman for the Pennsylvania Health Department, said the initial report was "not completed and unintentionally posted."
"The report on the site now is correct," she added.
She declined to answer questions about details included in the initial report but omitted from the now official report.
Einstein officials did not respond to requests for comment but the facility did submit a corrective action plan to the state including updating procedures for responding to adverse events. The hospital, however, said it disputed the state's right to access certain internal documents relating to the cases.
The two cases detailed in the official report include a patient admitted to the facility on Aug. 3, 2016 "looking pale and unresponsive." A subsequent entry stated the patient later died from "excessive sedation leading to hypo-ventilation and brain anoxia."
The second case detailed in the final report involved a patient who underwent a colonoscopy on September of 2016 and left "against medical advice."
The patient, according to the report, returned the next day with worsening abdominal pain and eventually passed away.
The report cites Einstein for failing to conduct a root cause analysis, a process designed to find the root cause of an error, on the two cases.
Omitted from the final report were details of the other two cases. One involved a patient who choked on a sandwich and the other a patient who was injured during an esophageal in-tubation.
Both the final and initial reports cited Einstein for refusing to allow state inspectors to interview staff involved in one of the cited cases.

Thursday, December 14, 2017

Restraint Violations Cited In Patient Death

By Walter F. Roche Jr.

An "agitated and belligerent" patient at a Camp Hill, Penn. hospital died of apparent asphyxiation when staffers, assisted by security guards, attempted to place him in both arm and ankle restraints.
 Details of the Sept. 26 incident are contained in a critical report from the state Health Department, which cited the Holy Spirit Hospital for multiple violations of rules limiting the use of restraints and requirements to report serious incidents to state officials.
According to the report, which was just made public, the patient was being forcibly held down while others attempted to apply ankle and wrist restraints.
One staffer "held the patient's hands while his nurse applied the restraint to his left wrist. The patient continued to kick, yell and thrash around on the bed," a hospital employee told the state surveyors.
"The patient attempted several times to kick staff and security," the report continues, adding that the patient, at one point, bit one of the security guards.
"I was attempting to grab his right wrist," one staffer told state inspectors, "when the patient stopped struggling and I noticed that the patient began to foam at the mouth and his eyes began to close."
According to the report a "code blue" was called but attempts to revive the patient, whose face had turned blue, failed and he was declared dead.
Subsequent examination concluded he suffered "acute anoxic brain injury."
Holy Spirit, part of the Geisinger Health System, was cited for multiple violations including the failure to report a "serious event" to state officials within 24 hours of its occurrence. The 307-bed Cumberland County facility was also cited for failing to report the incident to the patient's parents.
The report states Holy Spirit refused to let the state inspectors question four employees believed to have knowledge of the incident, another violation.
Asked to comment on the incident, Holy Spirit spokeswoman, Lori Moran wrote in an email,"While we would prefer not to restrain patients, at times such measures are indicated for the safety of all involved."
"We are saddened whenever a patient passes away," the statement continues,"and are confident that the care our team provided was consistent with Geisinger Holy Spirit's mission of delivering professional and compassionate care to all."
As Moran indicated, the hospital did submit a corrective action plan to the state. The report shows the initial hospital response, however, was sent back and a subsequent submission was accepted.
The state report followed a two-day mid-October visit to the facility by investigators from the state Public Health Department.
The inspectors reviewed earlier records involving the patient which showed that while there was one order for the use of wrist restraints, it was amended a day later authorizing the use of mitts. There was no order for ankle restraints. The report notes a state requirement that any restraints be limited to the least restrictive form.
The records also show two of the staffers involved in the incident had not undergone annual education sessions on the use of restraints "including training in how to respond to signs of physical and psychological distress (for example positional asphyxia)."
Moran said the corrective action plan included new training for staffers, including the use of videos on the proper way to restrain patient and revised policies on the use of restraints and notification requirements.
As for reporting the incident within 24 hours, the records showed the hospital did not report it until Oct. 12 and that initial report did not disclose there was a death. On Oct. 23 a new report finally disclosed the death.
Asked for an explanation one staffer told the state inspectors,"I did not feel this was an usual incident."
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Tuesday, December 12, 2017

Spent Telemetry Batteries Cited in Flatline

By Walter F. Roche Jr.

Telemetry failures due to spent batteries and the failure of staff to monitor equipment have been cited in two recent cases at the same Philadelphia area hospital where one patient was found pulseless and another coded.
In a 17-page report, Pennsylvania Health Department surveyors found that staff at the Crozer-Chester Medical Center in Chester, PA. failed to monitor alarms showing whether cardiac monitors were functioning. properly.
As a result monitors for two patients failed to operate for as long as an hour and forty five minutes before staffers responded.
In the first case a nurse noted that on reporting for her shift on Aug. 16 at 11:45 p.m. she went to print a patient's cardiac monitor strip and found the monitor displaying the message "Replace Battery."
When she went to that patient's room the patient "was noted to have no pulse and no resp."
The monitoring strip showed a flatline (no cardiac tracing) from 9:43 p.m. to 10:45 p.m. when the patient was found pulseless."
The report concludes staffers did not respond to the "Replace Battery" message at either the nursing station or hallway telemetry. As a result the alarm was not functioning for 62 minutes.
The inspectors, who conducted a review of hospital records from Oct. 12 to Oct. 24, of hospital records, determined that no staffer was specifically assigned to watch telemetry monitors at the nursing station on all four telemetry units."
In addition, though the batteries were supposed to be changed every eight hours, no specific person was assigned that task.
The inspectors also learned that the hospital had switched battery suppliers in June and nurses had noted that the new batteries sometimes didn't last the expected eight hours.
In the second case, which came just two days after the first, the report states that the telemetry unit in question had "no cardiac tracing for one hour and 45 minutes prior to the patient's code due to a dead battery."
"Further interviews confirmed that (Patient 1 and Patient 2) patients' rights to care in a safe setting were not met," the report states.
Noting that none of the nurses were equipped with telemetry linked phones, the report concludes, "All of these factors led to an unsafe setting."
Asked to respond to the report a spokesman said that the hospital itself had reported the incidents to the state but he did not respond to questions about the outcome for the two patients.
"As part of our ongoing quality control efforts, we identified a possible issue with our telemetry monitoring process and self-reported it to the Pennsylvania Department of Health," spokesman Andrew Bastin wrote in an e-mail response to questions.
He added that the hospital worked with state health officials to develop an acceptable plan of correction and that the plan finally implemented went beyond the department's recommendations. He said the change in battery brands was due to a change of vendors.
"There was no meaningful difference in the cost of the new batteries," the email stated.
According to the statement, additional staff have been hired to monitor all telemetry operations and a central telemetry monitoring system was established at the Crozer-Chester Medical Center.
According to the plan of correction, logs will also be kept to ensure that the required monitoring is taking place.
Contact: wfrochejr999@gmail.com

Monday, December 4, 2017

Abuse Cited in Nashville Alzheimer's Unit

By Walter F. Roche Jr.

Two incidents of patient on patient abuse in a secured Alzheimer's unit, have prompted state health officials to order a freeze on new admissions and impose a $5,000 fine on a Nashville, Tenn. nursing home.
The freeze was ordered Monday by state Health Commissioner John Dreyzehner for the Greenhills Nursing and Rehabilitation Center, a 150-bed facility. He cited conditions that "are or are likely to be detrimental to the health, safety or welfare of the patients."
In both October incidents patients were injured by other patients prompting the state to cite nursing home officials for failure to prevent neglect and failure to protect, prevent, report and investigate allegations of abuse.
"I almost died last night," one of the victim's stated the day after suffering bruises to her arm and face at the hands of another patient.
Neither of the incidents were reported to the nursing home's abuse coordinator, as required under the nursing home's own policy, inspectors found.
A staffer questioned by a state inspector about the incident said, "I didn't see it as abuse. It's a secure unit with combative patients. This wasn't the first time."
In the second incident a resident in the unit grabbed a fire extinguisher and began spraying residents and staff. The patient also hit another patient.
In a 16-page inspection report inspectors cited an array of violations of state requirements ranging from the failure to provide adequate staff, to failure to train and retrain staffers in the handling of patients suffering from dementia and Alzheimer's Disease.
Records at the nursing home examined by inspectors showed only 54 of 239 staffers who worked at the facility had participated in staff development training to deal with "dysfunctional behavior and catastrophic reaction in residents" between Jan. 20, 2017 and October.
According to the report the nursing home utilized some half dozen private agencies to fill nursing slots. The contracts specifically stated that it was the nursing home's responsibility to provide staff training.
Deficiencies were also noted in training staffers in medication management.
Other deficiencies included the failure to fully evaluate patients before placing them in a secured unit and failure to prevent falls. The inspectors found that 19 residents had falls between June 20 and the October incidents.
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