Friday, June 8, 2018

Abington Hospital Cited in Medication Error

By Walter F. Roche Jr.

Reaching back nearly two years, Pennsylvania health officials have cited Abington Hospital for a "mishap" in which a patient was given a dose of a medication four times the strength prescribed by her doctor.
In a six-page report recently made public, the health department surveyors found that a resident physician and his supervisor failed to properly perform a medication reconciliation process when the woman appeared at the hospital's emergency room on July 10, 2016.
Instead, the report states, they relied on the incorrect information provided by the patient's husband. Apparently overlooked was a fax from the woman's primary care physician, sent about 10 minutes before the wrong dosage was administered, listing the correct dosage of the cardiac medication, 5 milligrams three times per day.
A few hours after the patient was administered 20 milligrams of Midodrine on July 11, her blood pressure shot to 207/100 and she reported dizziness and other symptoms requiring rapid response team intervention.
In addition to failing to note the fax from the PCP, the surveyors cited the staffers for failing to ask the patient herself about the correct dosage.
Hospital records reviewed by the state showed the patient's own hospital record stated,"of note a mishap was made on the patient's medication reconciliation during admission."
Abington, a 665-bed facility, is part of Abington-Jefferson Health.
The report states that there was no record that the patient herself "was given the opportunity to confirm what the spouse may have discussed with the medical resident/attending physician in regards to their Midodrine dosage."
Stating that "there was no documented evidence that the patient was determined to be disoriented, incompetent and/or unable to answer questions," the report states that there was "no documented evidence that the admitting medical resident and/or their supervising attending physician made a good faith effort to involve the patient in the medication reconciliation process."
The report cites a notation in the patient's record stating "Minimizing midodrine dose may help prevent future hemorrhages."
A subsequent hospital record from the Rapid Response Team questioned the 20 milligram dosage.
"Need to clarify the dose of Midordine as 20 mg three times a day, seems a very high dose which is usually not recommended,"the record states, adding that no further doses should be administered.
"Hold Midodrine for now," the note states.
Abington filed a plan of correction which included the implementation in the pharmacy system to alert pharmacists when dosage of Midordine exceeds the usual range."
Hospital officials did not respond to a series of questions about the incident.

Tuesday, June 5, 2018

Friends Hospital Cited in Patient Assault, Secret Taping

By Walter F. Roche Jr.

A Philadelphia behavioral hospital videotaped patients without their consent and captured one of those patient being assaulted twice within a matter of minutes.
In a lengthy report, inspectors from the Pennsylvania Health Department found the violations during a four day visit to Friends Hospital, a facility that has been the subject of prior critical reports from the state agency. Though it was founded as a Quaker institution, the hospital is now owned by a for-profit chain, Universal Health Services.
The report was made public last week even though the hospital had not yet filed an approved plan of correction. Friends officials did not respond to requests for comment.
"The facility failed to protect and promote the rights of each patient by failing to ensure that informed consent was obtained prior to the video recording of direct patient care," the report states.
Despite the widespread use of cameras, inspectors learned that there were no viewing monitors for staff to monitor patient safety.
All patients and staff, the report states, were under constant camera surveillance. The surveyors found "multiple ceiling mounted cameras dispersed through out patient care areas."
A subsequent review of patient records showed a patient who was admitted to the facility on March 24 had not signed a consent to video surveillance.
Video showed the same patient being kicked by two of his peers on March 31. The patient was "taken down to the floor and the other two punched his face with hands and feet."
A second assault on the same patient occurred minutes later, according to the report.
Records showed the patient had swelling over his right eye and had substantial nose bleeding.
As for the cameras, the report states, patients who don't sign the consent form are "still recorded through out their hospital stay without their explicit consent or knowledge."
The surveyors also found that records of the incident were inaccurate.
The facility "failed to ensure patient care was provided in a safe setting," the report concludes.
Other findings involving a second patient who was so heavily sedated she could barely sit up.
"Patient was asleep and barely rousable in the day room," according to the report.
Still other findings included the improper use of physical and chemical restraints. Staffers also failed to recheck the blood pressure of a patient who had a seriously low pressure in a routine check and those same staffers failed to notify the patient's physician of the reading.

Friday, May 25, 2018

Wills Eye Cited by State Surveyors

By Walter F. Roche Jr.

Philadelphia's Wills Eye Hospital has been cited for a series of rules violations including failure to provide appropriate and required radiology services for more than a half dozen patients.
In an 18-page report, state Health Department inspectors found that between November of last year and January of 2018 the hospital was shuttling patients to an outpatient radiology center located in the same building but run by the adjacent Thomas Jefferson University Hospital.
Cathy Moss, the Wills spokeswoman, said that after the April inspection the hospital sought and obtained a waiver from the requirement to provide the radiology services in-house.
Moss said that while Wills "has a very large sophisticated imaging center that is fully utilized for our patients," the hospital has an agreement with Jefferson for "neurological imaging needs."
She said Wills own imaging department is for vision/eye-only imaging.
Moss said that the state had also approved Wills' corrective action plan for other violations cited in the April report.
Those other citations included the failure to verify the performance of pre-surgical patient anesthesia evaluations within 48 hours before surgery, failure for surgeons to verify a patient's identity after placement on the operating table and failure to document that a follow up anesthesia evaluation was performed within 24 hours following surgery.
"It was determined that the facility failed to ensure that patients had been identified by the surgeons after placement on the operating table prior to the procedure for 13 of 13 surgical records reviewed," the report states.
Moss characterized the citations as paperwork issues that did not impact the quality of patient care. The inspection, which began in February, was performed as part of the annual state license renewal process.
Still other deficiencies included the failure to include the names of participating fellows on consent forms and in one case there was no signed consent form.

Wednesday, May 16, 2018

UPMC Mercy Cited in Deaths

By Walter F. Roche Jr.

A Pittsburgh hospital has been cited by state regulators for misuse of patient restraints including four cases where patients died within 24-hours of being in restraints.
In a detailed report recently posted by the state Health Department, UPMC Mercy was cited for placing patients in restraints without a doctor's orders, failing to release patients from restraints as soon as possible and failing to report to federal officials that patients who died had been in restraints within 24 hours of their deaths.
The report is only the latest of several to detail violations of restraint requirements in Pennsylvania hospitals.
Officials of the 404-bed acute care hospital filed a plan of correction in response to the report in which they disclosed a number of steps being taken to correct the problems. The plan includes a re-education program for staffers on the limitations for restraint use and an auditing system to ensure that the corrective actions are being followed.
The hospital also said it would establish a daily mortality list which will be reviewed to ensure that deaths are being properly reported to the state and the U.S. Centers for Medicare and Medicaid Services.
UPMC officials did not respond to requests for comment.
In the state Health Department report surveyors found that four patients, identified only as MR2, MR3, MR4 and MR7, had died either while in restraints or within 24 hours of being released from restraints. Nonetheless the hospital failed to include that information in filings with state and federal health officials.
"Hospitals must reports deaths associated with the use of seclusion or restraint," the report states.
In another finding the surveyors found that, despite a policy forbidding it, physicians had issued standing orders for use of restraints on an as needed basis.
"Orders for the use of restraints must never be written as a standing order," the report states.
Regarding the release of patients from restraints as soon as possible, the inspectors found that one patient was kept in restraints even though the patient was described as "quite calm."
Asked about the finding a hospital staffer told the surveyor," These are newer nurses. It looks like they need further education."
Another deficiency noted in the report was the failure to include in four patients' records the symptoms that warranted the use of restraints, such as side rails.
Yet another deficiency cited was the failure to follow a physician's orders regarding the use of restraints. In one case cited a patient was put in restraints even though the doctor had not ordered it.

Saturday, May 12, 2018

PA Transplant Programs By Annual Volume, Star Rating

Milton S. Hershey Medical Center

Heart 5 (2 Stars)
Kidney 28 (2 Stars)
Liver 17 (3 Stars)
Hospital of the University of Pennsylvania

Heart 72 (2 Stars)
Kidney 188 (2 Stars)
Kidney-Pancreas 2 (2 Stars)
Liver 127 (4 Stars)
Lung 94 (3 Stars)
Pancreas 1 (not assessed)
Thomas Jefferson University Hospital

Heart 4 (not assessed)
Kidney 96 (4 Stars)
Kidney Pancreas 5 (3 Stars)
Liver 73 (not assessed)
Pancreas 2 (not assessed)
Pinnacle Harrisburg

Kidney 42 (not assessed)

Children's Hospital of Philadelphia

Heart 9 (4 Stars)
Kidney 16 (not assessed)
Liver 17 (4 Stars)
Lung 4 (not assessed)
Children's Hospital Pittsburgh

Heart 12 (2 Stars)
Kidney 18 (4 Stars)
Lung 2 (not assessed)
Liver 38 (5 Stars)
Pancreas 3 (2 Stars)
Intestine 4 (not assessed)

UPMC ____

Heart 26 (4 Stars)
Intestine 1 (not assessed)
Kidney 215 (4 Stars)
Kidney Pancreas 6 (3 Stars)
Liver 110 (1 Star)
Lung 60 (4 Stars)
Pancreas 2 (not assessed)

Allegheny General

Heart 26 (3 Stars)
Kidney 107 (2 Stars)
Liver 31 (2 Stars)
Kidney Pancreas 4 (3 Stars)
Temple University Hospital

Heart Lung 1 (Not assessed)
Heart 18 (5 Stars)
Kidney 46 (3 Stars)
Kidney Pancreas 6 (4 Stars)
Liver 5 (2 Stars)
Lung 105 (2 Stars)

Source: Scientific Registry of Transplant Patients
Under the five star system programs with the higher number of stars are rated above those with fewer stars

Deficiencies Cited in PA Transplant Programs

By Walter F. Roche Jr.

Federal inspectors have cited Pennsylvania transplant programs over the past two years for a variety of deficiencies including a program at the Milton S. Hershey Medical Center which was cited for a death rate in the heart transplant program more than twice the expected level,
The Hershey report from the U.S. Center's for Medicare and Medicaid Services is just one of a dozen issued by the federal agency over the past two years on Pennsylvania transplant programs.
A review of those reports shows that many of the programs were found to have the same or similar deficiencies. The inspections are required every three years to maintain certification in the federally funded Medicare program.
Inspectors found only one program, a small one at Saint Christopher's Hospital for Children in Philadelphia, that had no deficiencies. According to CMS officials the responsibility for conducting the inspections alternates between CMS and the state health departments. The Pennsylvania Health Department will be conducting the next round of inspections of transplant programs in the state.
Data from the private agency, the Scientific Registry of Transplant Patients,that gathers details of all approved transplant programs shows that nearly 1,800 transplants were performed in Pennsylvania in the 12 month period ending June 30, 2017.
The Hospital of the University of Pennsylvania reported 484 transplants, the largest number in the state, followed by UPMC with 420. Kidney transplants at HUP totaled 188 while UPMC reported 215. Temple University Hospital had 275 cases with lung transplants topping the list with 105.
Penn State's Milton S. Hershey Medical Center was cited for the number of heart transplant patients who died within one year of surgery. While 3.73 deaths were expected, the actual number was eight during the period from July 1, 2012 t0 Dec. 30 2014.
Hospital spokesman Scott Gilbert noted the report was based on cases handled between 2012 and 2014.
"In the more than three year's since, we have implemented a series of changes that have improved outcomes for our heart transplant patients," he wrote in an email response to questions.
In its response to CMS, Hershey said it had also revised its selection standards for heart transplants.
Gilbert said other improvements include an electronic reporting system to better track adverse events. He said Hershey also engaged an outside consultant to improve the heart transplant program.
Hershey was also cited for failing to notify CMS of a change in the person acting as the primary transplant surgeon. Waiting list deficiencies included failure to update a patient's status for five months while such changes must be made within 24 hours.

At Children's Hospital of Philadelphia surveyors reported that while 1.47 graft failures were expected between July 1, 2012 and Dec. 31 2014, the actual number was 4. Stating that the number was "significantly higher than expected," the report states the number was considered "unacceptable."
Asked about the findings, a CHOP spokeswoman said she could not comment.
Other findings in the report include the lack of all required documentation that the organ donor was found suitable for the recipient prior to surgery.
CHOP also was cited for the apparent lack of participation of some members of a multi-disciplinary team in all phases of each individual case. According to the report, CHOP did not properly screen adverse events and some staffers lacked specific training on transplants. A transplant coordinator, according to the report, was not properly trained.
In its plan of correction the hospital agreed to ensure selection criteria was in place and that documents certifying a blood match of recipient and donor were properly maintained. CHOP also agreed to perform audits to ensure its plan of correction was being followed.

Allegheny General Hospital in Pittsburgh was cited in a March 10, 2016 CMS report for the same lack of verification of blood type matches between recipients and donors. And like CHOP it was cited for failure of all assigned staffers to participate in a multidisciplinary team assigned to oversee each case.
Surveyors found that Allegheny General did not meet requirements for promptly updating waiting lists and did not have a process in place to inform patients or their families of adverse events.
Though the hospital reported there were no adverse events in 2014 and 2015, the surveyors found three cases that should have been in that category. In two cases a death occurred and in a third a patient had to be returned for additional surgery.
Dan Laurent, spokesman for the hospital, said that a plan of correction was approved and implemented and the hospital's certification remains in place. He said some of the changes involved simple language adjustments.
He noted the survey was conducted more than three years ago and major improvements were made in the interim.
Among the improvements, he said, was implementation a more robust process for identifying adverse events.
He said 164 transplants were performed at the hospital in 2017 including 104 kidney transplants.
At Children's Hospital in Pittsburgh surveyors found that the selection criteria for placing transplant patients on a waiting list was not always stated.
As with several other facilities, the hospital, part of UPMC, was cited for failing to properly document the matching of blood types between patients and donors. The hospital also failed to immediately inform a patient or fsmily member promptly of a change in status.
The hospital also was cited for failure to have all assigned staffers participate in all phases of a transplant patient's case, from selection to discharge.
The hospital filed a plan of correction in which it promised to improve its selection criteria and to require that surgeons complete documentation that donors and patients were properly matched by blood type and other criteria. Improvements also were made in the reporting and analysis of adverse events. according to the plan of correction.
AT UPMC's Pinnacle Hospital in Harrisburg CMS surveyors issued a 19-page report citing the facility for failure to notify he agency of a key staff change and failure to properly investigate adverse events. As with several other facilities Pinnacle was cited for failing to promptly remove a patient from the waiting list.
Spokeswoman Kelly McCall said the hospital "fully implemented a corrective action plan, several elements of which were completed during the survey."
At UPMC in Pittsburgh CMS surveyors found that the volume of patients, seven in a three year period, in an an intestinal and multivisceral program was below the desired level.
Spokesman Lawerence Synett said,"UPMC swiftly implemented a detailed corrective action plan, and is fully compliant with all regulations. The program is operational and fully certified, with our team currently following over 100 patients for long-term care."
He said advances in nutritional therapy and non-transplant care have reduced the need for intestinal and multi-visceral transplants nationwide, with only five adult and pediatric centers performing more than 10 in 2017.
Other items in the 113-page UPMC report are the same or similar to several other Pennsylvania programs including delayed removal of patients from waiting lists and failing to properly document the patient and donor have matched blood types prior to surgery. UPMC officials blamed some of those problems on computer programs.
One verification was dated three days after the surgery, according to the report. A patient who had dropped out of the program was not taken off the waiting list for 17 days, surveyors reported.


Gail Benner

The report on Jefferson report cites the facility for inactivity in one program. There were only 21 patients over three years while a 10 patient per year minimum is required. What program was this and what is its current status.
o Please see our press release regarding the voluntary pause of our heart transplant program here; and another when we reactivated.
· Other deficiencies include the failure to document the involvement of a pharmacist, dietitian and social worker in all phases of the transplant procedure. What has been done to correct these deficiencies and other in the report?
o Our multidisciplinary transplant team regularly assesses the quality of our programs to ensure the best possible care for our patients. This includes incorporating feedback from reviews and accreditations. Items that are identified by an accrediting body, such as CMS and UNOS, are immediately addressed through a robust quality assurance and performance improvement program. Staff have been re-educated regarding required documentation and performance is tracked by a compliance manager on a regular basis. Recent reports show consistent compliance.
· Can you provide annual statistics on the number of transplant cases in each of the four programs?
o SRTR provides a comprehensive database of transplant statistics.

Kelly McCall Pinnacle
UPMC Pinnacle is full committed to keeping patients safe and strives every day to implement to the best safety measures available. UPMC Pinnacle fully implemented a detailed corrective action plan, several elements of which were completed during the survey. UPMC Pinnacle’s kidney and pancreas transplant program is fully certified, and our team cares for nearly 1,600 patients each year.

Scott Gilbert Hershey

transplant certification
Gilbert, Scott

Yesterday, 4:30 PM

The data you are referencing reflects heart transplant surgeries that took place at Penn State Health Milton S. Hershey Medical Center from July 1, 2012 through December 31, 2014. In the more than three years since, we have implemented a series of changes that have improved outcomes for our heart transplant patients.

Out of our own realization that we needed to do better for our patients, we engaged a nationally recognized consulting firm in December 2015 to conduct an independent review of our adult heart transplant program. This occurred prior to the CMS report you are referencing, which was published in March 2016.

We incorporated the recommendations of the independent firm into our processes. Specific steps taken as a result of that work include:
Creation of an electronic reporting process for adverse events that has allowed us to better use the data generated to enact quality improvements.
Increased staffing, including the addition of a dietitian and a pharmacist whose expertise is included in all phases of care.
Consistent use of our electronic systems to generate required patient notifications.

In the more than three years since the period you reference, outcomes in our heart transplant program have improved significantly. Nonetheless, we will always strive to do better and meet the high expectations to which we and our patients hold our heart transplant program.

Thank you for the opportunity to provide this important context for your story.

Scott Gilbert
Team Lead, Public Relations and Multimedia
Office of Marketing and Communications
Penn State Health | Penn State College of Medicine
P.O. Box 850, CA260

UPMC is fully committed to patient safety and is always investigating new and improved ways to improve transplant policies and practices.

Regarding the report you reference on the multivisceral/intestinal transplant program and other questions, UPMC swiftly implemented a detailed corrective action plan, and is fully compliant with all regulations. The program is operational and fully certified, with our team currently following over 100 patients for long-term care. Advances in nutritional therapy and non-transplant care have reduced the need for these kinds of transplants nationwide, with only five adult and pediatric centers performing more than 10 in 2017.

Have a great day,


Lawerence Synett

Thursday, April 19, 2018

Philly Nursing Home Had Prior Citations

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.