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.

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.

Thursday, October 19, 2017

Highly Critical Einstein Report Pulled Back

By Walter F. Roche Jr.

A highly critical inspection report on the Albert Einstein Medical Center has been taken of the Pennsylvania Health Department web site and an agency official says it had been posted prematurely.
The report, which was posted in early August, cited the 701 bed facility for failing to adequately investigate four unexpected patient deaths.
The report also charged that Einstein refused to allow state surveyors to interview key staffers and examine records.
Einstein declined comment when first contacted by this blog prior to the posting of a report on the report in early August.
April Hutcheson, spokeswoman for the state Health Department said the report had been posted "inadvertently. It was not complete. It will be posted 41 days after is complete."'
 Although that report was based on a May visit to Einstein by state inspectors, the state has posted a subsequent Einstein report based on a visit in August. In addition the now withdrawn report was based on cases dating back to 2016.
The withdrawn report cited Einstein for failure to comply with state and federal requirements in serious cases "involving the clinical care of a patient that results in death or compromises patient safety."
The report included a plan of correction filed by Einstein in which they promised to institute new patient safety protocols and to use those new standards for all serious events beginning on July 1.
The hospital, however, repeated the assertion that some of the records sought by state inspectors at the time of the inspection are "peer review, protected, privileged documents, entitled to protection under federal and state law."
The first case cited was of a patient who was admitted in July of 2016 was found looking pale and unresponsive on Aug. 7, 2016. Records examined by the surveyors attributed the death to "excessive sedative use leading to hypo-ventilation and brain anoxia."
The second case involved an unidentified patient who underwent a colonoscopy on Sept. 23, 2016 only to return "with worsening abdominal pain." The report states.
The patient, who had apparently suffered a colon rupture, did not survive. The report states the patient had gone home the same day as the procedure against medical advice.
In the third case a patient reported to the emergency room on June 21, 2016 with "agitation and psychiatric symptoms."
When the patient asked for something to eat a sandwich was provided. The patient was choking by the time the nurse returned. The patient subsequently expired.
State inspectors asked for records showing required reviews were performed following the death. "None were provided," the inspection report stated.
Another death occurred following an esophageal intubation in February. When state surveyors asked for documentation and the results of a "root cause analysis," they were told the documents were confidential and "protected."
In addition, the report states, that no completion dates were included for "action items" set to be implemented as a result of the incidents.
Cited in the report was a requirement by licensed health facilities to "track medical errors and adverse patient events, analyze their causes and implement preventive actions and mechanisms."

Wednesday, September 27, 2017

Hershey Self Reported Citation Cases

A spokesman for the Milton S. Hershey Medical Center said today that the five citations against the facility in August occurred in a state inspection triggered by the facility self reporting issues relating to the care of three patients, two of whom did not survive.
The five citations were issued in August by the state Health Department of Health.

Tuesday, September 26, 2017

Hershey Cited in 3 More Cases, 2 Deaths

By Walter F. Roche Jr.

Just weeks after being cited for deficiencies in the care of a child who died while under treatment, the Milton S. Hershey Medical Center has been cited for mishandling three more cases. In two of the three cases, one involving a child, the patients died.
The medical center located in Hershey, PA. was cited in August for the three new cases following a special monitoring survey by inspectors from the Pennsylvania Department of Health The July visit, according to a center spokesman,  was triggered when the facility self reported the three cases.
 A total of five citations were issued in the new report dated Aug. 2..
In two of the new cases, the facility was cited for failure to provide expected emergency services.
"The patient has a right to expect emergency procedures to be implemented without unnecessary delay," the report states.
In the case of an unidentified child under treatment for an infection, the state inspectors concluded that Hershey personnel unduly delayed calling for a rapid response team .
'The team "should have been called much earlier, about noon," the state report continues citing an interview with a hospital employee.
The team was not called until 3:30 p.m. or 3.5 hours later, the inspectors found.
Hershey, in response to questions about the pediatric case said the patient had "lifelong medical deficiencies" and was being treated for a "serious infection."  Hershey was cited for failing to timely upgrade the patient's care by a transfer to the pediatric intensive care unit, the hospital acknowledged
In a recent prior report, Hershey was cited for failing to adequately monitor a boy who had been placed in a heating blanket. The patient's temperature had reached 107 degrees when finally discovered. That patient also died.
In the second new case an adult patient who was later found to have suffered a stroke was not quickly provided a drug that could have minimized symptoms.  The delay was attributed to a difference of opinion among staffers about the correct diagnosis, Hershey officials stated.
When the stroke diagnosis was finally made, it was too late to administer the drug. The report does not detail the patient's ultimate outcome.
In the third new case, there was a delay in getting medication to a patient who had suffered a fall and suffered a sub-dural hematoma.
According to the report there was an hour and 47 minute delay between the time the drug was ordered and when it was finally delivered.
An employee who was questioned by state inspectors about the delay, said an emergency department nurse had said the drug would not be administrated immediately because a shift change was scheduled shortly. That nurse later denied any recollection of making that comment.
In its statement in response to questions about the new citations, Hershey said, "Instances such as this are inconsistent with the high quality care our community has come to expect from us - and which we expect from ourselves. We deeply regret when we fall short of those expectations."


Friday, September 15, 2017

Nursing Home Fined; Admissions Barred

By Walter F. Roche Jr.

A Nashville nursing home has been fined $15,000 and barred from admitting any new patients after an inspection showed multiple violations of state and federal laws and regulations.
Records show that dozens of patients of the facility needing critical maintenance medication went multiple times without getting doses of drugs for diabetes, hypertension and convulsions.
The fine  and admissions freeze was imposed on the  Nashville Metro Care and Rehabilitation, formerly know as Crestview Health and Rehabilitation, located at 2030 25th Ave. in Nashville.
The action was announced by Tennessee Health Commissioner John Dreyzehner. The nursing home has 111 licensed beds. The suspension followed an on-site inspection from Aug. 21-28.
Dreyzehner said a special monitor has been appointed to oversee the operation of the facility in the interim.
The state inspectors found violations in three general areas; physician services, nursing services and medication administration.
The 65-page inspection report cited multiple sanitation and maintenance problems including  pervasive urine smells.
One nursing home worker told an inspector, "The urine smell is between (room) 204 and 205. It's not as strong as it usually is."
The report shows the home had long term staffing problems and at times only a single registered nurse was on duty for an entire shift. It often relied on staffing agencies, but home administrators could not produce a contract with those agencies.
The staffing shortage, inspectors found, led to multiple missed medications for dozens of patients on life sustaining drugs.
When a nursing home administrator was asked about the persistent staff shortage, the response was, "I feel like you caught me with my pants down."
The report cites the home for failure to respond when an unattended patient fell out of bed. The patient's hip fracture was not detected until several days later. According to the report the facility failed to notify the patient's doctor or his legal representative.
The nursing home employee who discovered the patient on the floor told inspectors she didn't know how to enter the incident into the computer system.

Wednesday, September 13, 2017

UPMC Hospital Cited for Improperly Filming Patient

By Walter F. Roche Jr.

In what one participant described as a "circus," physicians and other employees of a Bedford County hospital crowded into an operating room late last year to observe and take pictures and videos of an unidentified patient being treated for a genital injury.
The group, which included several employees not involved in the treatment of the patient, took pictures and videos on their personal cell phones of the patient who had not given consent, all in violation of official hospital policy.
The Dec. 23, 2016 incident was investigated by the Pennsylvania Health Department and resulted in a 41-page report which concluded that the UPMC Bedford Memorial Hospital "failed to protect the personal privacy, dignity and respect of the patient."
The 59-bed hospital in Everett, PA is part of the UPMC system. UPMC officials did not respond to a request for comment.
The hospital filed a plan of correction in which officials promised to initiate policy changes to prevent a recurrence. They also reported that physicians and employees involved were suspended for periods of up to 28 days.
The incident came to light when a hospital employee "came forward to complain about photographs that were circulating around the hospital of a patient under anesthesia while in the operating room."
The inspection report, which was recently made public, does not provide complete details on the patient's genital injury, but does state that the surgery involved the removal of a foreign body.
One hospital employee told state investigators, "I was curious. I couldn't imagine how the patient did it," adding, "There was quite a crowd"in the operating room.
"We never had a circus like this before," an employee told investigators.
The report was the result of an on site investigation from May 23 of this year to June 9.
According to the report, in addition to violating the patient's privacy rights, the incident violated a variety of hospital rules, including a requirement that only approved hospital equipment could be used to take photos of patients.
The state investigators also gathered evidence that the Dec. 23, 2016 incident was not the first time patients had been photographed without consent.
"Generally we don't tell that to a patient," one employee told investigators. "It was a medical curiosity," the employee continued. "We are a small hospital. It is commonplace for everyone to know what cases are coming in."
Another employee told state investigators, "I do take pictures of genito-urinary anomalies for educational purposes."
The employee said he did warn colleagues stating, "Stop this is a HIPPA (Health Insurance Portability and Accountability Act) violation," adding that he told the curious employees they could return to the operating room once the patient was anesthetized.
According to the report, a surgeon said before the surgery finally began, "That's enough. We've got to get going."
Another employee stated that at one point, some onlookers were asked to leave "because they did not have enough eye protection for everyone due to the sparks flying from the tools that were being used."
The 2016 incident came more than two years after the disclosure that a physician took a selfie with comedian Joan Rivers, during the surgery that ended her life.

Friday, August 18, 2017

Hershey Hospital Cited in Death of Six-Year Old

By Walter F. Roche Jr.

A Hershey hospital has been cited by Pennsylvania health officials for failing to report the unexpected death of a six-year-old boy and failure to follow expected standards of care in treating him.
According to a lengthy state inspection report, the Milton S. Hershey Medical Center only notified the Pennsylvania Health Department of the death after an anonymous informant had reported the Jan. 11 death months after it occurred. Under state law and regulations the death should have been reported within 24 hours of its occurrence.
In response to questions about the citation, the medical center issued a statement acknowledging the delay in reporting the incident and also the fact that there was a 10 hour gap in the recording of the patient's temperature.
"The facility failed to meet the emergency needs of a patient with acceptable standards of practice," the inspection report states.
The boy, who was brought to the hospital's emergency room on Jan. 10, was placed in a warming device due to a low temperature. He had a temperature of 107.6 degrees when he was found unresponsive the next day.
"There were no vitals,"the inspection report states, adding that hospital staffers acknowledged the warming device, called a Bair Hugger," had been on high all night.
He was pronounced dead at 5:39 p.m. on Jan. 11.
In addition to the failure to report the death, the hospital was cited for failing to adequately train employees and failing to follow the warming device manufacturer's guidelines calling for temperature checks every 10 to 20 minutes.
In its statement, the medical center said management did not become aware of the incident until notified by the state following the anonymous complaint to the state Patient Safety Authority.
"This situation raised serious issues, and our response has been equally serious" the hospital said in its statement.
Acknowledging that the state found a total of five violations, the medical center
termed the incident an "unacceptable failure" and said corrective action was initiated  as soon as it received notice of the anonymous complaint.
 The state sent inspectors to the hospital on April 12 and they completed their review the next day. Because the inspectors declared a state of "immediate jeopardy," the hospital was required to respond immediately with a corrective action plan. The "immediate jeopardy" was lifted on April 13.
In its statement the hospital said the boy was suffering from "ongoing, complex and life limiting health issues" and "presumed sepsis" when he was brought to the emergency room in January.
After he was found unresponsive the next day, he was taken to the the hospital's pediatric intensive care unit but died later in the day.
The hospital said its own investigation found "an agency nurse was overseeing the child's care during the 10-hour gap in temperature documentation, and no one involved in the child's care reported the incident to our Patient Safety Department."
In its inspection report, the state said that the nurse in question said she knew she took the patient's temperature but forgot to document it.
"I did not have the computer with me. I was probably busy with something else," she told the inspectors.
The state found that although the nurse had been hired a year earlier, there were no evaluations in her file and core competency for use of the warming device "was not completed."
According to the hospital statement, the facility now limits the use of the warming devices to operating rooms "where patients are continuously attended."
Other steps include training for staffers, including those hired through an agency, on the use of such devices and audits to ensure serious incidents are properly reported.
"As an organization that holds itself accountable for providing the highest quality care while protecting the safety of patients, employees and visitors, we recognize this situation was an unacceptable failure," the hospital said in its statement.

Tuesday, August 15, 2017

Philly Hospital Cited in 4 Patient Deaths

By Walter F. Roche Jr.

A major Philadelphia hospital has been cited by state health regulators for failure to fully investigate the cause of four unexpected patient deaths in 2016, refusing to provide official records and refusing to allow state surveyors to interview key staffers involved in the incidents.
In a report recently posted on its web page, the Pennsylvania Health Department cited the 701 bed  Albert Einstein Medical Center for failure to comply with state and federal requirements in serious cases "involving the clinical care of a patient that results in death or compromises patient safety."
The report was the result of a site visit to the Einstein facility described as an unannounced complaint investigation in early May.
Einstein officials filed a plan of correction in which they promised to institute new patient safety protocols and to use those new standards for all serious events beginning on July 1.
The hospital, however, repeated the assertion that some of the records sought by state inspectors at the time of the inspection are "peer review, protected, privileged documents, entitled to protection under federal and state law."
Einstein officials did not respond to a request for comment.
In the first case cited a deceased patient who had been admitted in late July of 2016 was found looking pale and unresponsive on Aug. 7, 2016. Records examined by the surveyors attributed the death to "excessive sedative use leading to hypo-ventilation and brain anoxia."
In a second case an unidentified patient underwent a colonoscopy on Sept. 23, 2016 and returned "with worsening abdominal pain."
The patient had elected to leave after the procedure "against medical advice," the report states.
The patient, who had apparently suffered a colon rupture, did not survive.
In another case a patient reported to the emergency room on June 21, 2016 with "agitation and psychiatric symptoms."
The patient asked for something to eat and was given a sandwich. The nurse returned to find the patient choking. The patient subsequently expired.
State inspectors asked for records showing required reviews were performed following the death. "None were provided," the inspection report states.
Another death occurred following an esophageal intubation in February. When state surveyors asked for documentation and the results of a "root cause analysis," they were told the documents were confidential and "protected."
In addition, the report states, that no completion dates were included for "action items" set to be implemented as a result of the incidents.
Cited in the report was a requirement by licensed health facilities to "track medical errors and adverse patient events, analyze their causes and implement preventive actions and mechanisms."