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.