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.