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."

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.

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.

Monday, November 27, 2017

TN Nursing Home Gets Top Fine, Critical Inspection

By Walter F. Roche

A Memphis, Tenn. nursing home has been hit with record fines after inspectors found widespread neglect resulting in actual harm to multiple patients including one who died after transfer to a hospital where an exam showed he had widespread untreated wounds infested with maggots.
The fines totaling $50,000 were imposed on the Ashton Place Health and Rehabilitation Center, a 211 bed facility. It was the highest such penalty ever imposed.
In addition to the fines Tennessee Health Commissioner John Dreyzehner ordered a freeze on any new admissions to the facility and appointed a monitor to oversee its operations.
The 98-page inspection report, which prompted Dreyzehner's action, cites multiple cases of patients suffering actual physical harm due to failure to follow a physician's orders, failure to administer prescribed drugs and failure to inform physicians' of their patients deteriorating condition.
A male patient who was admitted to the home on July 26 of this year with no visible wounds ended up being transferred to a hospital multiple times for ulcers and ultimately died on Oct. 11. Hospital staffers found maggots in wounds that appeared to be untreated.
The state surveyors noted that the records of wounds on the patient recorded at the nursing home when he was placed in an ambulance omitted at least five wounds that were found by hospital staffers minutes later.
The report states that nursing home records indicated the patient also was not given the pain medications his doctor had prescribed.
"He was not assessed regularly nor did he receive his pain medication regularly," the report states.
Neglect and poor care was also detailed for other patients, including a female patient suffering from ovarian cancer whose worsening condition was not reported to her doctor. She died on Oct. 24.
When a state surveyor asked a home employee what she did when the patient vomited, the worker said, "No I didn't give her anything. If they only vomit once, we watch them."
In that patient's case, the report states she was apparently given a medication that wasn't prescribed.
The report was highly critical of managers at the facility and noted that top officials contended they were unaware of the problems reported by direct care staffers.
Home managers "failed to ensure that care was provided as called for in care plans for five of 16 residents," the report states.
According to the report, the home's medical director stated, "I have support, no direction. I have talked (to them) about the staff they have here. I don't have much confidence in them."
One resident, the report states, was left sitting in her own stools for five hours. Another was found choking after she pulled out her oxygen tube.
Records showed another patient apparently did not get 37 of 106 prescribed doses of Lyrica and 29 of 106 prescribed doses of morphine.

Hospital Faulted in Patient Suicide

By Walter F. Roche Jr.

A Philadelphia area behavioral hospital has been cited for multiple violations of state and federal requirements in the death of a patient who died by suicide on Sept. 30.
The unnamed Eagleville Hospital patient was found unresponsive hanging from a doorknob less than 12 hours after staffers noted an acute and alarming change in mental status. That change prompted an order for hourly checks on the individual.
Nonetheless the patient was found unresponsive later in the day. Attempts at resuscitation were unsuccessful and death was declared at 6 p.m.
When state surveyors arrived at the 308-bed Montgomery County facility on Oct. 5, they issued  a declaration of "immediate jeopardy," an action requiring an immediate response from managers of the hospital. Inspectors cited "an unsafe physical environment."
The alarm was sounded because inspectors found patient rooms had not been configured to meet so-called anti-ligature requirements. They cited the presence of duffel bag strings along with door knobs and other protrusions that could be used in a suicide.
The victim had used a doorknob in the successful suicide attempt, the report indicates.
The patient was found "unresponsive and pulseless, sitting on the floor with a band around the neck attached to a doorknob."
Hospital officials responded to the immediate jeopardy declaration with a corrective action plan. That plan included the addition of staffers, increased patient monitoring and additional assessments of patients for suicide risk.
The "immediate jeopardy" was lifted at 9:15 p.m., the report states.
Eagleville officials did not respond to a request for comment on the state report.
The inspectors found additional violations, however, including a hospital policy banning any visitors for detox patients. The state requires that visitors be given access.
Eagleville was also cited for failing to monitor the suicide victim for the effects of a drug administered a little over 12 hours before the suicide was discovered.
The hospital is a non-profit corporation and its most recent tax return listed revenues of $40.5 million and expenses of $36.3 million.
Eagleville is not the first area behavioral facility to be cited in the suicide death of a patient. In 2015
 a patient at the Kirkbride Center drowned himself in a bucket while taking a shower.
The Philadelphia facility was cited for failing to keep the patient under constant observation after a prior suicide attempt only two days earlier. That patient drowned in a rubbish bucket.
Friends Hospital, also in Philadelphia, was cited for similar violations in the suicide death of a patient on Nov. 12 of 2016. That patient was found hanging from a door hinge.

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.