Thursday, December 14, 2017
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
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
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.