Sunday, October 14, 2018

Blue Mountain Fails to Make Corrections


By Walter F. Roche Jr.

A Carbon County Pennsylvania hospital failed to implement a promised plan of correction and has been cited yet again for the same deficiencies along with failure to do what was already promised.
State Health Department surveyors found in August the same deficiencies at two sites of the Blue Mountain Hospital that they had months earlier.
The problems were found at the St. Lukes's Gnaden Huetten campus in Lehighton and a second St. Luke's site in Palmerton, according to an inspection report recently made public.
"The Blue Mountain Hospital failed to correct the previously identified deficient practices," the report states.
State surveyors visited the facilities between July 31 and Aug. 3.
Among those deficiencies were the lack of treatment plans for individual patients and failing to maintain safety and sanitation requirements.
Part of the St Luke's University Health Network, the hospital had promised to fully implement a plan of correction by May 10. Network officials did not immediately respond to requests for comment.
Other deficiencies include the failure to use the proper voluntary commitment forms and failure to eliminate or remedy items that could be used for suicides.
The facility also failed to involve the required staffers, such as social workers, psychiatrists and nurses, in the development of individual treatment plans.
In a new plan of correction the hospital promised to move some elderly patients to "a newly renovated safer location. The Palmerton campus includes a 16-bed older adult behavioral unit.
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Friday, October 5, 2018

Hospital Cited in Treatment of Dementia Patient


By Walter F. Roche Jr.

A Bucks County hospital has been cited by the Pennsylvania Health Department for failure to follow proper procedures in the treatment of an elderly patient suffering from dementia and Alzheimer's disease.
In a 24-page report just made public, state surveyors said the patient had been placed in restraints "to prevent inadvertent injury," but the Lower Bucks Hospital in Bristol failed to follow rules limiting the time a patient can be kept in restraints without review and approval from a physician.
The rules also require facility personnel to monitor the patient while restraints are in use but the records did not indicate that procedure was followed. The findings came during a mid-August visit to the hospital.
According to the inspection report the patient was administered doses of Ativan more frequently than prescribed by a staff physician.
"Ativan was administered too soon," the report states.
A hospital spokeswoman said a plan of correction had been submitted to the state and officials were confident it would be approved.
"Our hospital has a remarkable treatment record, and we remain committed to providing the most effective care for the good of all members of our community," Michelle Aliprantis, a hospital spokeswoman, wrote in an email response to questions.
The unidentified patient cited in the report was admitted to the hospital in early June of this year. She was accompanied by a daughter who had power of attorney for her mother. The records indicate the patient became hypotensive during a surgical procedure.
According to the report in addition to Ativan the patient was administered Klonopin and Percocet The justification for the use of those two drugs was not found in the hospital records.
However the patient had been treated with Trazadone by her personal physician. The surveyors faulted the hospital for changing the medication without the consent of the patient or the person holding her power of attorney.
The state surveyors noted that the patient's records contained conflicting information on how a drug was to be administered.
The orders, the report states, should have been clarified.
Finally, the report states, when the hospital transferred the patient to a nursing home on June 12, they failed to provide adequate information from the patient's record.
The hospital was also cited for failing to re-appoint a staff physician along with other staffing deficiencies, including failure to have a full time supervisor of emergency services.
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Sunday, September 30, 2018

Anti-Psychotic Drug Use Plummets in TN Homes


By Walter F. Roche Jr.

The use of potentially deadly anti-psychotic medications on long term Tennessee nursing home patients suffering from dementia has plummeted since 2012, the result of the combined efforts of the state and private partners.
Data provided Friday by the U.S. Centers for Medicare and Medicaid Services shows the percentage of long-stay Tennessee nursing home patients diagnosed with dementia and being treated with anti-psychotics dropped to 15.1 percent in the first quarter of 2018. That represents a 49.5 percent drop from the the 30 percent rate recorded in 2012, when CMS began assembling quarterly statistics.
And while Tennessee ranked 49th among other states in 2012, the latest data show it ranks 30th.
The effort to reduce the use of anti-psychotics on dementia patients is based on the fact that the drugs can be deadly for these patients.
In fact the drugs are required to carry a so-called black box label warning users of the potential deadly result for dementia patients. Among the drugs requiring the black box label are risperidone, haloperidol and perphenazine.

WARNING: Increased mortality in elderly patients with dementia related psychoses


The new data is being hailed by Tennessee Health Commissioner John Dreyzehner who called the achievement an "important milestone."
State health officials credit efforts by the nursing homes themselves along with QSource, the Eden Alternative and Vanderbilt University for educational efforts that included regional conferences along with webinars.
The seminars included a 2014 session in Nashville where nursing home employees from the region were told about alternative methods for the treatment of dementia patients, such as re-direction.
"The evidence is that the use of these drugs actually shortens peoples lives," Bill Thomas of the non-profit Eden Alternative said at the May 2014 session.
The CMS data show Hawaii was ranked first in the latest data with only 6.2 percent use of anti-psychotic on dementia patients.
Oklahoma had the worst rate with 19.4 percent use of anti-psychotics on long-term nursing home dementia patients. Not far behind was Alabama where a 19.2 percent rate was reported.
"Working together we've improved the quality of life for more than 3,500 elderly Tennesseans," said Beth Hercher of QSource, a private agency that monitors health care quality.
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Saturday, September 29, 2018

PA Vets Home Cited Again


By Walter F. Roche Jr.

A state run nursing home for veterans in Pittsburgh has been cited yet again by Pennsylvania Health Department surveyors for providing poor care to patients.
In a recently released 19-page report state inspectors found that one patient who had fallen and cracked a rib complained of pain but didn't get an X-ray of the rib cage until five days after the initial June 17 incident.
The 236-bed Southwestern Veterans Center was cited not only for the delay in care but also for failing to report the incident as required under state law and regulation.
In fact the report states there were two other incidents, both involving delayed wound care, in which officials at the facility failed to report as required.
The report based on an August on-site visit came just a month after the same facility was cited for negligence when a paraplegic patient was left sitting on a bed pan for two days.
The latest report was based on an annual inspection to determine if the facility still qualified for the federally funded Medicare and Medicaid programs.
The patient with the rib injury fell from a wheelchair on June 17. Although X-rays were taken of his knee and hip, the X-ray of his ribs did not happen until June 22 after he had reported continued pain and was refusing to eat. The X-ray showed a rib fracture and a partially collapsed lung.
The other incidents that went unreported included a patient with a persistent cough and a wound that went untreated.
According to the report the patient had a temperature of 102.3 and had vomited, yet no report was filed.
A third incident involved a patient who had behavioral incidents after falling out of his bed. The report states the facility failed to report a significant change in a patient's condition.
The two patients, the report states, had to endure extended waits, one of up to 56 days, before having their wounds properly assessed.
Still other findings included failure to maintain sanitary conditions in the main dish washing area and failure to properly label drugs.
The home filed a plan of correction in which they promised to change policies and procedures to assure there would be no recurrences.
Officials of the state Department of Military and Veterans Affairs, which runs the state veterans homes did not immediately respond to requests for comment.
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Monday, September 24, 2018

Harrisburg Hospital Cited for Lack of Coverage


By Walter F. Roche Jr.

A Harrisburg hospital has been cited for failure to have physicians available when five patients needed emergency resuscitation earlier this year.
In a report made public last week the Select Specialty Hospital at 111 S. Front St. was cited by the state Health Department for failure to have a physician available between late May and mid-July.
In the most recent case a patient was found unresponsive on July 15. Records reviewed by state Health Department surveyors show the patient was administered a series of medication, including epinephrine, as part of the resuscitation effort. But, the report states, there was no evidence a physician had authenticated the orders, a requirement under state regulations.
Four nearly identical cases were cited in the report.
The facility, the report dated Aug. 3 states, "failed to ensure medical services were available for patients in need of emergency services."
The report notes that the hospital was licensed to provide Level IV emergency services. A facility licensed at that level must have a physician available or on call at all times, according to the report.
Staffers questioned during the Aug. 2 site visit told state inspectors that the hospital's contract for those services changed in October of 2017. Prior to that physicians were called on all codes.
A plan of correction filed by the hospital stated that the situation was corrected in early August to ensure that there would be immediate physician coverage for all codes
Requests for comment from the hospital or its parent company, Select Medical, went unanswered.
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Thursday, September 13, 2018

Maryville Nursing Home Cited, Fined


By Walter F. Roche Jr

The Tennessee Health Department has ordered an admissions freeze and imposed fines totaling $45,000 on a 181-bed Maryville nursing home after state inspectors found that seven patients at the facility fell nearly 40 times resulting in serious injuries including broken bones and a subdural hematoma.
Commissioner John Dreyzehner said the freeze on admissions was issued against Asbury Place. In addition to the fines and freeze on new admissions he appointed a special monitor to oversee operation of the facility.
The repeated falls by patients at the facility along with numerous other deficiencies were detailed in a 106-page inspection report based on a visit to the nursing home in August.
According to the inspection report seven residents fell a combined total of 39 times with most of those fall occurring in the lastseven months. Nine serious injuries were reported including a subdural hematoma and brokem hips and legs.
The report concludes that the seven were placed in an environment "detrimental to their, health safety and welfare."
One patient, the report states, fell nine times between July of 2017 and July of 2018. Two of those falls resulted in traumatic injury, including a broken hip.
"We are working closely with state and federal health regulatory agencies to ensure full compliance with quality of care guidelines. We are addressing all of the opportunities identified for us in our health care center, and are actively reviewing, and where necessary, strengthening our policies and procedures to make improvements for those we serve," said Cathy Canning, spokeswoman for Asbury.
The report faults the facility for failing to fully investigate the falls, failing to develop care plans to prevent future falls and failing to implement care plans in those cases where a plan was actually provided.
The plans themselves, the state surveyors found, often did not actually address the patient's needs.
When the surveyors questioned staffers about the falls and the failure to address them, they were told,"It is simply an unavoidable risk."
Another told surveyors, "You can't really prevent falls."
"We have a few frequent fallers," another employee told the state surveyors..
A patient who fell in a bathroom at the home on Aug. 2 suffered an acute sub-dural hematoma.
The surveyors concluded that the care plan developed for another patient who suffered four falls was "inappropriate."
A male patient, who fell four times between January and July, suffered a fracture of a cervical bone and required stitches as a result of the last fall.
In some cases the surveyors found that even when appropriate care plan was ordered, it was often not implemented t
That included a female patient who fell in February, June and July who suffered a broken hip.
Again, the report states, the plan developed for the woman "was not appropriate" and she suffered two major in juries.
A resident "who was severely cognitively impaired initially admitted to the facility for rehabilitation after suffering a fractured hip, had a total of 10 falls between April 5 and June 13," the report states.
Still other deficiencies included failing to address the pain being suffered by one patient, failing to respond to excessive weight loss and not properly treating a patient with a pressure ulcer.
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NASHVILLE, Tenn. – Tennessee Health Commissioner John Dreyzehner, MD, MPH has suspended new admissions of residents to Asbury Place at Maryville effective Sept. 12, 2018. In addition, Dreyzehner has imposed nine state monetary penalties in the amount of $5,000 each for a total assessment of $45,000. A special monitor has been appointed to review the facility’s
operations.

Asbury Place at Maryville, a 181 bed nursing home located at 2648 Sevierville Road in Maryville was ordered not to admit any new residents based on conditions found during a complaint survey conducted August 13 – August 20, 2018. The investigation was completed Sept. 4. During the investigation, surveyors found violations of the following standards: administration and basic services.

The Commissioner of Health may suspend admissions to a nursing home when conditions are determined to be, or are likely to be, detrimental to the health, safety or welfare of the residents. The order to suspend admissions remains effective until conditions have been and continue to remain corrected. A copy of the order must be posted at the public entrance where it can be plainly seen.

The nursing home has the right to a hearing regarding the suspension of admissions before the Board for Licensing Health Care Facilities or an administrative judge.

The mission of the Tennessee Department of Health is to protect, promote and improve the health and prosperity of people in Tennessee. TDH has facilities in all 95 counties and provides direct services for more than one in five Tennesseans annually as well as indirect services for everyone in the state, including emergency response to health threats, licensure of health professionals, regulation of health care facilities and inspection of food service establishments. Learn more about TDH services and programs at www.tn.gov/health.

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Monday, September 10, 2018

Texas Compounder Licensed by TN RX Board

By Walter F. Roche Jr.

The Tennessee Pharmacy Board has licensed a Texas pharmacy to issue sterile compounded and other prescription drugs in the state even though the company says it has suspended the production of sterile drugs while its facilities are upgraded.
Records from the state board show Surecare Specialty Pharmacy of El Paso, Texas was issued a pharmacy license in early July. But you won't find Surecare listed among the licensed pharmacies on the board's website. It was removed from the automated listing shortly after a request was submitted for a copy of the application.
Asked why the listing was removed, Shelley Walker, a spokeswoman for the state Health Department, said the action was taken under the state law creating the pharmacy panel. She declined to be more specific.
The unusual handling of the Texas drug compounding firm comes in a state where drug compounding has become controversial. It was a Massachusetts drug firm that compounded fungus laden steroids that took the lives of 15 Tennessee patients in a 2012 outbreak. Dozens more were sickened.
More recently an unnamed out-of-state drug compounder provided the Tennessee Corrections Department with the drug, Midazolam, needed to execute Billy Ray Irick on Aug. 9. Under state law the identity of that compounder has been kept secret.
Repeated calls and emails to Surecare and its majority owner Paul Galbiati went unanswered.
The Surecare web site lists sterile compounding as one of its services, but also states, "We
are currently updating our clean room facilities to meet changes in standards and regulations – at which time we will continue to offer sterile compounding for our patients."
According to the company's application, a predecessor firm, Sun City Compounding, was cited by the Texas Pharmacy Board for failing to disclose the fact that an officer had been convicted of a misdemeanor.
Surecare's Tennessee application lists Alexandra Abbas as the pharmacist in charge.
Abbas was also cited by the Texas board in 2017 for allowing an unlicensed technician to perform technician's duties. She was employed in a different pharmacy at the time.
Though Abbas was listed as the pharmacist-in-charge in the Tennessee application, the company web site lists a different pharmacist in that position.
The application lists Galbiati as a 60 percent owner, 4AM Consulting with 30 percent, James A. Lyle at 5 percent and Ed Anderson with 5 percent. Neither Lyle or Anderson responded to requests for comment.
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Admissions Halted at Memphis Assisted Living


By Walter F. Roche Jr.

Tennessee health officials have fined and suspended new admissions to a Memphis assisted living facility where a resident suffered a heat stroke and dehydration after being left unattended outside on a hot early summer day.
State Health Commissioner John Dreyzehner imposed a $3,000 fine and ordered the admissions freeze on Foxbridge Assisted Living and Memory Care, part of Inspirit Senior Living, based in McLean, Va.
According to a six-page inspection report, the 91-year-old resident was found unresponsive at about 3 p.m. on June 6 of this year while sitting on a dock near the cottage where he lived.
The report concludes the facility failed to provide a safe environment for the resident who suffered from dementia, high blood pressure and heart disease. He had been admitted to the facility on Nov. 30, 2017.
Inspirit President David Mcharg said that after reviewing the state report they have decided to appeal all claims.
"We will work cooperatively with the Department of Health to resolve this matter. We look forward to continuing to provide excellent care and remain dedicated to the quality of life of our residents," he wrote in an email response to questions.
According to the report the resident was diagnosed with heat stroke and dehydration after he was transferred to a local hospital. He was discharged six days later to a local nursing home.
One Foxbridge staff member told state surveyors they were not sure how long he had been sitting out in the sun on a day that a "Code Orange" had been declared. His body temperature, according to hospital records' ranged up to 103 degrees.
"He was real hot," one of the care providers told surveyors, "and his arms and face were red."
"He did not drink any water while he was outside," another employee told the state inspectors, adding that he used a cup of water to pour over the resident when he was found unresponsive.
The facility, located at 2180 Magnum Road, sits on an 8-acre site that includes five cottages and a fishing pond. The resident was living in a cottage which houses 20 seniors. Two staffers were on duty at the time of the incident.
According to the report the resident was placed on an office chair and rolled back to the cottage where he was laid on the floor and cooled with ice until emergency responders arrived.
"There was no documentation the resident frequently stayed outdoors or was monitored outdoors," the report concludes.
"Apparently he was exposed to a lot of heat and left for several hours," the report states.
The resident's wife told surveyors said that her husband was unconscious for two hours.
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Monday, August 27, 2018

Vets Home Charged with Neglect


By Walter F. Roche Jr.

A paraplegic under treatment in a state run veterans nursing home in Pittsburgh, PA. was left sitting on a bedpan for two days and suffered a pressure ulcer and other injuries as a result, according to a report by state health surveyors.
The report, just recently released, charges the facility with neglect for not only leaving the veteran helpless on a bedpan for two days but also for failing to provide a shower and other sanitary care services.
The unnamed patient at the Southwestern Veterans Center in Pittsburgh suffered actual harm due to a bedpan being left underneath him and peri-care not being completed, the report states.
"The facility failed to make certain that a resident was free from neglect," the report states.
After examining the nursing homes records on a July 12 visit to the 236-bed facility, the surveyors found that the male patient was placed on a special bedpan on June 10 and was found on July 12 in the same situation.
A staffer who examined him at 6:30 a.m. on June 12 described a reddened area approximately 24.5 centimeters in diameter and 1.5 centimeters thick.
The patient had an "unstageable pressure ulcer" and "injury to the sacrum" with the bedpan being a contributing factor.
The patient remained on the bedpan even though he was supposed to be turned and repositioned periodically to prevent bedsores.
Interviews with several staffers involved in the patient's care acknowledged to state surveyors that the bedpan was not removed until June 12.
The report states that additionally the patient was not provided with needed peri-care over the two day period.
The inspectors also cited the center for failing to develop a comprehensive care plan for the same patient.
The facility filed a plan of correction reported the patient's care was being re-assessed and wound care was being provided. They also promised to re-assess the needs of other residents who needed to be repositioned.
The plan also includes staff retraining by Affinity Health Services.The plan calls for the corrective actions to be in place by Sept. 1
Asked to comment on the report, Joan Nissley, spokeswoman for the Department of Military and Veterans Affairs said,"The Bureau ensures that the provision of quality health care for our Veteran residents and their spouses is delivered in a caring and dignified manner while ensuring compliance with all appropriate state and federal regulations."

Tuesday, August 21, 2018

3rd Hospital Cited in a Telemetry Death


By Walter F. Roche Jr.

Another Pennsylvania hospital has been cited in a telemetry related failure that ended with a patient's death.
In a report recently made public, state health department surveyors found that two staff nurses at the New Lifecare Hospital of Mechanicsburg failed to respond when told the alarm had sounded on a patient on a cardiac monitor.
In fact, the report states, the patient was off the monitor for approximately 45 minutes before a technician found the patient "pale, no pulse and non-responsive."
After reviewing the records of the June 8 incident, state surveyors declared a "state of immediate jeopardy." The emergency declaration requires hospital officials to come up with an immediate corrective action plan. They did so nearly four hours later.
The patient, the report states, was resuscitated and transferred to another hospital but died less than an hour after transfer.
The report comes as the facility is in the final phases of a permanent shutdown. Announced last month the closure is expected to become final early next month putting over 120 employees out of work.
Officials of New Lifecare and its parent company did not respond to requests for comment.
Hospital records show the patient was checked at 1:30 p.m. and "no distress was noted." It was nearly an hour later at 2:28 p.m. when a technician found the patient unresponsive. The patient was revived and transferred to another hospital at 3:03 p.m.
The surveyors reported that the technician monitoring the cardiac monitor "told two nurses that the patient's monitor needed to be checked." Neither nurse went to check the patient.
The report cites the hospital for failure to follow the orders of the patient's doctor, who had ordered a cardiac monitor.
In addition the surveyors found that staffers administered drugs to the patient without a physician's orders. In fact in three other cases of patients who suffered cardiac incidents, medicines were administered without a doctor's orders.
In yet another finding the surveyors found that hospital staffers failed to follow proper procedures in the use of restraints.
The hospital filed a plan of correction which included a new requirement for nurses to respond to monitor alarms within two minutes. They also agreed to have on-call physicians available 24 hours a day-seven days a week and to re-educate staff on proper procedures for medications.
Earlier this year state surveyors cited the Nazareth Hospital in Philadelphia for failure to respond to a telemetry alarm.More recently Paoli Hospital was cited when a telemetry alarm was repeatedly silenced despite the lack of response from staffers assigned to check on the patient.
In both cases, the patient died.
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Tuesday, August 14, 2018

Greeneville Nursing Home Cited in Elopement


By Walter F. Roche Jr.

A Greeneville, Tenn. nursing home has been hit with an admissions freeze and $6,000 in fines after a patient with a history of wandering walked out of the facility and fell down a 15 foot embankment suffering cuts and abrasions.
The patient's elopement occurred despite the fact that an alarm sounded as he walked out the door of the Loughlin Care Center on July 3.
State surveyors reported that a receptionist heard the alarm, peeked out the door but did nothing else.
"I peeked through the window and didn't see anything so I reset the alarm," the receptionist told state inspectors. "No one told me to go outside and look around," she added.
A landscape worker subsequently went into the home and reported that a patient had fallen and was injured.
The state report on the incident concludes that the 90-bed facility placed the patient "in an environment detrimental to health, safety and welfare."
Meaghan K. Smith, a spokeswoman for Ballad Health, which owns the facility, said the incident was self reported to state triggering an automatic investigation
She said the facility had filed a corrective action plan that was accepted by federal officials but she acknowledged that the plan had yet to win state approval.
State Health Commissioner Dr. John Dreyzehner ordered a freeze on any new admissions to the home, imposed the $6,000 in fines and appointed a special monitor to oversee actions at the facility.
Nursing home records show the patient was wearing an alarm device known as a "Wanderguard" which triggered the alarm when he followed a landscape worker out the front door.
The state surveyors also noted that five other patients at the facility with a wandering history had improperly installed Wanderguards. The alarms were attached to their wheelchairs not to their legs.
As for the patient who was injured, surveyors noted that he actually fell three times during the incident.
The unnamed patient was treated for cuts and bruises at a local emergency room, the report states.
The facility failed to ensure that a resident was free from an avoidable accident with injuries, the report concludes.
The Ballad spokeswoman said,"The nursing home has taken steps to update security procedures that we believe will improve the safety of residents and mitigate the opportunity for any similar event to occur in the future."
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Too Many Empty Beds Found on Medicare Review


By Walter F. Roche Jr.

A suburban Philadelphia hospital specializing in bariatric surgery has been cited during a Medicare re-certification review for going without a single inpatient on nearly 150 days.
Surveyors from the Pennsylvania Health Department concluded that the Forest Health Medical Center in Langhorne Bucks County failed to meet the requirements of the federally funded Medicare and Medicaid programs.
The hospital did not file a plan of correction acceptable to the state.
Surveyors examining hospital records found that the patient census was zero on 146 days over a 12 month period.
"The facility failed to function as a hospital," the report states.
The Pennsylvania facility is part of the Barix Clinics, which operates a similar facility in Ypsilanti Mich. According to the report the hospital is licensed for 23 medical/surgical beds.
Health is licensed for xxx beds but the records showed they went largely unoccupied.
State inspectors visited the facility on two separate days, March 5 and June 18, and on both of those days the in-patient census was zero.
The hospital, the report states, was "not primarily engaged in providing services to inpatients."
In the review of hospital records the surveyors found that the average daily census ranged from 1.2 to 3.3 patients.
Hospital officials did not respond for requests for comment.
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Wednesday, August 8, 2018

State Cites Paoli Hospital in Telemetry Error, Death


By Walter F. Roche Jr.

For the second time in four months state officials have cited a Pennsylvania hospital in a case in which a patient died when a telemetry alarm was mishandled.
In a report on the Paoli Hospital recently made public, state surveyors found that the hospital, part of Main Line Health, "failed to ensure a safe environment for patients on telemetry."
Main Line spokeswoman Bridget G. Therriault said the incident was "the result of employee conduct that violated our established policies, procedures, and practices. The employee involved in the event has been terminated."
The state health surveyor, who visited the 231 bed hospital on a complaint investigation on June 18. declared a state of "immediate jeopardy" after reviewing records relating to the patient who died on May 28.
The hospital responded with an immediate action plan later in the day and the state of immediate jeopardy was lifted. However the facility has yet to file an overall plan of correction satisfying state regulators.
"An approved plan of correction is not on file," the report states.
The records reviewed showed that when a nurse went to check on the patient, whose condition was being monitored electronically, there was no pulse. A code blue was called but the patient had "passed away," the report states.
The records reviewed by the state showed the technician assigned to monitor the patient had repeatedly silenced the alarm after attempts to reach the nurse assigned to the patient failed. Those failed efforts came on phones provided by the facility.
The inspection showed there were repeated failures with the phone system with battery packs falling out. The report states that some employees had resorted to taping the batteries in an attempt to keep them in place. Other used elastics to hold the batteries in position.
The battery pack falls out all the time, one hospital employee told the surveyor.
According to the report not only did calls go unanswered but callers could not even leave a message. And even when calls went through reception was poor.
"Sometimes we cannot make or receive calls," another employee told the surveyor.
The report states that alarms were not to be silenced until the monitor technician "establishes direct verbal contact with the nurse caring for the patient."
Earlier this year the state health agency cited Nazareth Hospital in a similar incident involving a death and the failure of telemetry monitoring.
Therriault said the hospital instituted its own investigation of the incident and reported it to state officials.
"In addition, we reached out to the patient’s family to explain what had transpired and to express our deepest regrets," she said in response to questions.
She said that hospital officials were continuing to work with state officials in developing action plans to address outstanding issues.
"Main Line Health’s first priority is to ensure the safety of all those who rely on us for care," she concluded.




Monday, July 30, 2018

Admissions Barred at Knoxville Nursing Home


By Walter F. Roche Jr.

New admissions to a Knoxville nursing home have been barred after state inspectors found that a patient there suffered fractures to both knees from an avoidable accident but didn't even get to see a physician for over a week.
Tennessee Health Commissioner John Dreyzehner ordered the admissions freeze and imposed $30,000 in fines on the Westmoreland Health and Rehabilitation Center, a 222 bed facility.
In a 55-page report state surveyors said the woman suffered the fractures on Nov. 11 of last year when a certified nursing assistant attempted to change the patient's sheets without the assistance of a second staffer, as had been ordered.
The patient slid off the bed and landed on her knees crying out in pain, according to the report.
"The fractures were extremely painful," the report states.
After reviewing nursing home records and interviewing staffers, the state inspectors found that despite the patient's repeated complaints of severe pain, X-Rays were not taken until five days after the fall and it was another four days before she was seen by an orthopedic specialist.
The unnamed woman was then hospitalized and treated for the fractures. She died on Dec. 18.
The state surveyors learned that the delay was apparently the result of a note posted at the nurses' station telling staffers they were not to contact the physician or his nurse practitioner "until contact has been made with the on-call nursing manager."
One staffer told the inspectors that the note disappeared after nursing home officials learned they were being sued.
The home's physician told the state surveyors he only learned of the bilateral fractures from their call. He told them he should have been notified about a fracture.
The report states that the physician and the home's director of nursing also never assessed the patient.
Under Dreyzehner's order the home was fined $5,000 each for six violations including failure to notify the physician of a significant change in a patient's condition and "placing a resident in an environment that was detrimental to their health, safety and welfare."
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Wednesday, July 11, 2018

Pa. Hospital Cited for Compounding Errors

By Walter F. Roche Jr.

In a scathing report that eerily echoed details of a five-year-old deadly national outbreak, a Pennsylvania hospital has been cited with multiple violations of drug compounding standards placing cancer patients in immediate jeopardy.
The findings by the Pennsylvania Health Department forced the Pottstown Hospital to immediately shutdown its cancer center pharmacy where supposedly sterile drugs were being compounded for administration to cancer patients.
The report concluded that hospital management and staffers "failed to ensure established procedures for hand hygiene and donning protective gear were followed for the compounding of hazardous drugs."
State surveyors observed staffers working under hoods without required protective gear. Numerous violations of the industry standard code known as Chapter 797 were observed.
Officials of Tower Health, the holding company for the hospital did not respond to requests for comment. The hospital did file a corrective action plan with the state in response to some but not all of the deficiencies.
State surveyors also cited Pottstown, a 232 bed facility, for an array of violations of the federally mandated Life Safety Code. The report states that the main hospital building "exceeds the maximum story height allowed" and multiple areas were found to lack the required fire rating.
Other violations also were noted in several areas other than the cancer center pharmacy.
Staffers failed to follow proper procedures for blood transfusions and mold was observed in an ice machine.
Still other deficiencies included failure to ensure the privacy of patient records, failure to maintain infection control in multiple areas and improper cleaning of endoscopy equipment.
IV bags were observed without expiration dates and expired gloves and drugs were also observed in the endoscopy area.
In the clean room where critical procedures were performed gaps were observed on counter tops, floors were damaged and even when microbial sample showed contamination, no action was taken. According to the report there were over 30 incidents of microbial growth without documented follow up.
The facility "failed to ensure environmental microbial samples were evaluated," the lengthy report states.
The descriptions in the report were similar to the court testimony in the recent trials of former officials of the New England Compounding Center, the company blamed for the 2012 fungal meningitis outbreak.
In those trials federal investigators described similar deviations from the 797 standards including the failure to take corrective action when environmental tests showed evidence of contamination in the clean rooms. The two NECC official were found guilty of racketeering, mail fraud and related charges and are now serving prison sentences.
Still other citations included failure to have adequate post anesthesia services for pediatric
surgical patients and failure to maintain proper temperatures in an operating room.
Pottstown was one of five hospitals purchased by Tower Health from Community Health Associates last year for $418 million.
Another hospital purchased from CHA was the Brandywine Hospital in Coatsville, which was also the subject of a recent critical health department report.
That facility was cited for failure to comply with the state Child Protective Services Act. According to the surveyors, hospital staffers watching a monitor observed a visitor touching a child in an appropriate manner but subsequently failed to properly report the incident immediately. Instead, a report was filed three days late, the report states. The incident occurred on Aug. 27, 2017, two months before the purchase.
Brandywine also was cited for failure to properly follow up on patients who had discharged themselves against medical advice.
The surveyors found that Brandywine failed to contact the patients' outpatient therapists.
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Friday, June 29, 2018

Reading Hospital Faulted in Patient Death


By Walter F. Roche Jr.

A Reading hospital has been cited for violations of state and federal law in the treatment of a 59-year-old woman who was critically injured in a two-car April accident and died later the same day.
In a 10-page report the Pennsylvania Health Department found that Saint Joseph Medical Center, part of Penn State Health, failed to stabilize the woman before having her airlifted to the Penn State Milton S. Hershey Medical Center.
The state surveyors found that the handling of Debra A. Becker's case violated the federal Emergency Medical Treatment and Labor Act (EMTALA), better known as the Anti-Dumping law.
In addition the report states that the hospital failed to comply with a state law requiring the reporting of serious or sentinel events to the department and a related state authority.
In a statement issued today officials of Penn State Health acknowledged that the Reading facility had been cited by state and federal officials.
"The hospital immediately began to implement measures to address these citations, as noted in a plan of correction the hospital submitted June 28. The plan is due July 2. We expect the plan to be posted publicly upon acceptance." the statement read.
According to the report, which does not name the victim, she was brought to the St. Joseph's emergency department at 9:54 a.m.following an accident in which her car was T-Boned.
The patient's daughter, Karin Vasquez of Lancaster, said the patient was her mother who died on April 28, the same day as the accident. Her mother died after being transferred to the Hershey Medical Center, also part of Penn State Health.
Vasquez said she was rebuffed in her attempts to get information from the Reading hospital.
"I didn't get any information,"she said.
All she was told, Vasquez said, was,"We did everything we could."
The state report however, found fault with what the hospital did while Becker was at the facility and even after she was airlifted by helicopter to Hershey.
Though an IV was inserted immediately after she arrived at the hospital shortly before 10 a.m., no fluid was started until an hour later. After a CAT scan and other tests were completed, the report states, her blood pressure had plummeted to 64/44.
Finally at 11:07 a.m. two liters of saline solution were started.
Meanwhile tests showed multiple rib fractures and likely complex lacerations of the spleen, according to the state report.
A half hour later, the report continues, the patient complained of difficulty breathing. She was also reported to be sweating profusely.
"Decision made for transfer to trauma facility," the report states citing hospital records.
Citing those hospital's record, the report states,"it was determined the facility failed to provide an appropriate transfer within the capability of the hospital."
A Hershey Medical Center staffer told state surveyors that they told their colleagues at St. Joseph that if the patient was unstable she "needs to go to the OR (operating room) and then be transferred."
However, the report states,"The patient did not go to the operating room" and "the surgeon (at St. Joseph) did not evaluate the patient."
At Hershey surgeons attempted to stop the bleeding but the patient's heart stopped and she could not be revived. Death was declared at 1:46 p.m., according to the report.
The state surveyors concluded that the hospital also failed to comply with the state Medical Care Availability and Reduction of Error Act (MCARE) by not notifying the Health Department and the Patient Safety Authority within 24 hours of the incident.
The report also faults the hospital for failure to notify the patient's family of a "serious event" within seven days.
Vasquez said the family has yet to receive any notification from the hospital. Nor were they informed of the state Health Department findings.
"I am more than sure this was my mother. I wish it wasn't," Vasquez said after reading a copy of the report provided by a reporter.
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Tuesday, June 26, 2018

Two More State Hospitals Cited


By Walter F. Roche Jr.

Two additional state run mental hospitals have been cited by Pennsylvania health regulators in recent inspections for violations of state and federal standards, including failure to properly sterilize meters used on diabetes patients.
The citations were issued in April and May to the Danville and Warren State Hospitals.
The state Health Department surveyors inspected the facilities to certify their continued inclusion in the federally funded Medicare and Medicaid programs.
The two reports are in addition to a 67-page report recently issued on the Norristown State Hospital. That highly critical report cited the Montgomery County facility for failing to eliminate ligature and other risks for patients known to be at risk for suicide.
The same failure was cited in the report on the Danville State Hospital, located in Montour County.
The hospital failed to ensure ligature risks were eliminated, the report states. Cited were electrical cords, door handles and television wires found by inspectors in patient care areas.
In another finding the health department said hospital administrators had failed to set specific performance standards for a variety of services provided by outside contractors.Those included dental, laundry and respiratory services.
Inspectors found the same deficiency in Norristown.
Other findings in Danville include failure to ensure a sanitary environment in food preparation areas where a pail of soapy water was observed on the same cart as food. Light fixtures in that same area "had a heavy accumulation" of grease and dust.
The hospital responded with a corrective action plan promising improvements in the cited areas including the dietary department.
At the Warren State Hospital in the northwest corner of the state, surveyors found the same deficiency regarding the establishment of performance standards for outside contractors.
They also found staffers were not following the recommended sterilization standards for glucometers used to check blood sugar levels. Instead of sterilizing after every use, a staffer told surveyors they only sterilized the meters at the end of the day.
Documentation for the sterilization was missing for 16 of 30 days reviewed, according to the report.
Like their Danville counterparts, officials from Warren filed a plan of correction in which they promised to correct all the deficiencies.
Officials of the Office of Human Services, which oversees the hospitals, did not respond to requests for comment.
The three remaining state mental hospitals have not been inspected in over a year.
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Friday, June 22, 2018

State Hospital Cited for "Immediate Jeopardy"


By Walter F. Roche Jr.

A state run Pennsylvania mental health facility has been cited for multiple deficiencies including placing patients deemed at risk for suicide in "immediate jeopardy."
In a 67-page report made public this week, the Pennsylvania Health Department also cited the Norristown State Hospital for multiple other deficiencies ranging from poor sanitation practices to improper overuse of restraints to serious pharmaceutical lapses.
The critical report comes amid recent controversy over the future of the facility which now occupies but a small part of a more than 220 acre site. The hospital is also operating under a consent decree stemming from a suit filed by the state chapter of the American Civil Liberties Union.
The inspection was made as part of a periodic review to determine eligibility for the federally funded Medicare and Medicaid programs.
The state health surveyors declared a state of "immediate jeopardy" shortly after their arrival at the hospital on May 7 at 1:15 p.m.
Cited in the report were multiple available means of suicide including door hinges, bathroom grab bars and air vents. The inspectors also were critical of the frequency at-risk patients were being observed.
In twelve of twelve patient areas with ligature and safety risks,"the facility failed to ensure adequate observation rounding was conducted."
According to the report the facility management put together an action plan that was accepted at 6:41 p.m. and the "immediate jeopardy" was abated hours after it was imposed. The action plan calls for increased screening for suicide risks, furniture replacement, replacing doors knobs and hinges and eliminating beds with wooden slats for at-risk patients.
"The safety and well-being of the individuals we serve is the top priority of the Wolf Administration. In response to the recent inspection, Norristown State Hospital immediately addressed the issues identified as posing an immediate risk to the patients," said department spokeswoman Rachel Kostelac.
The report was critical of management at the facility for failing to review service contracts to ensure those services were being provided in "a safe and effective manner" and failure "to ensure patients' rights" were protected in the use of restraints and seclusion.
The hospital management filed corrective action plans for some but not all of the deficiencies cited. For instance an acceptable plan of correction was filed in response to the charge that the facility "failed to ensure patient rights for restraint or seclusion were met."
The accepted plans of correction included staff re-education, new forms for restraint use to clarify the need for the least restrictive measures and audits to ensure that the corrective action plans were being followed.
Reviewing the use of restraints, the inspectors cited three of four individual patient records which failed to include proper justification for the restraints and failure to ensure that the least restrictive measures were considered first.
One patient record "revealed no documented evidence that restraint alternatives and/or de-escalation techniques were implemented and determined to be ineffective, prior to the application of a physical hold/restraint to protect a patient or others from harm."
The inspectors found that in some records, the staff didn't even disclose what restraint was used.
Still other deficiencies include the failure to develop and implement quality improvement plans or to even collect data needed to identify areas needing improvement.
In the review of pharmaceutical services, surveyors found that state and federal rules were not followed. In some cases they found "no documented evidence" that patients received the prescribed medications.
Staffers told state surveyors that discrepancies between the drugs dispensed and the drugs actually administered "has been going on since 2000."
In radiological services the inspectors found a failure to monitor staffers for excess exposure. Dental X-Ray equipment was operated even though its certification had expired almost a year earlier. In addition the department had a single lead apron for staff protection.
Laboratory services also were faulted and an inspection of a laboratory services area "revealed a dirty unkempt in appearance, disorganized cluttered environment with direct-patient care supplies." Leftover food was commingled with lab specimens in a refrigerator.
Hospital officials responded by shutting down the lab storage area and promising further corrective actions.
"The Department of Human Services and the Department of Health are working together to respond to the violations cited in the report to ensure the health and safety of individuals in care, and to ensure a comprehensive plan of correction is submitted and executed by Norristown State Hospital," Kostelac stated.
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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.
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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.
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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.
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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.
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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.
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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.
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Monday, April 16, 2018

Cardiac Monitor Silenced, Patient Dies


By Walter F. Roche Jr.

A monitor technician at a Philadelphia hospital turned off a cardiac monitor alarm and the patient was found dead about 20 minutes later during a routine check by a nurse, according to a report by the Pennsylvania Department of Health.
The report on the Nazareth Hospital in Northeast Philadelphia cited the facility for "failure to ensure the well being of the patient by failing to respond to a cardiac monitor alarm as per facility policy."
According to the inspection report, a monitor technician on duty on Dec. 7 of last year "did not correctly identify a change" and silenced the alarm without verifying the rhythm or notifying the nursing staff of the alarm.
Nazareth, part of the Mercy Health System declined, to answer a series of questions about the incident but issued a brief statement.
"The safety of our patients is our top priority, and we maintain strict procedures to promote a positive, healing environment and to ensure patient confidentiality," Christy McCabe wrote in an email response to questions.
"We work closely with the Pennsylvania Department of Health and other regulators to ensure we continually implement best practices for patient safety," the statement concluded.
McCabe did not respond to questions including whether any action was taken against the technician or whether the new telemetry equipment has been put into use.
Nazareth, a 200-bed hospital, did file a plan of correction with the state in which they promised to re-educate technician monitors. They also said those technicians were tested by a Feb. 28 deadline.
Nazareth also said it would install new telemetry equipment to help ensure the incident would not be repeated.
State inspectors, who visited Nazareth on Feb. 26 through Feb. 28, said records showed that by the time the nurse who found the patient called a code blue, more than 20 minutes had passed since the alarm sounded.
The patient could not be revived. The incident occurred late in the afternoon of Dec. 7.
The inspection report states that Nazareth failed to maintain good quality care and high professional standards by not following established cardiac monitors policies."
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Monday, April 9, 2018

Temple Behavioral Unit Cited Again.


By Walter F. Roche Jr.

For the second time this year Temple University Hospital has been cited by state health officials for issues at its behavioral unit at the so-called Episcopal campus.
In a 12-page report made public last week, the Pennsylvania Health Department said the facility failed to file a required report following an accusation of patient-on-patient abuse. The finding followed a two day review in February of the facility records.
"It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's rules and regulations for hospitals," the report states, adding that the state was not notified of a complaint of "patient-on-patient abuse."
The incident, the report states, occurred on Sept. 2 of last year when a patient reported to a staff nurse that a male patient had kissed her causing her to become upset.
The patient who filed the complaint also attempted to confront the male patient stating "I'm going to kick your a.."
The inspectors wrote that the patient had to be separated from the male patient and was redirected to her room and was given medication due to her agitation.
Temple was cited for failing to provide a safe environment "free from any form of abuse, harassment, exploitation and neglect."
Despite the incident, the inspectors said Temple failed to comply with a requirement to report complaints of abuse to the state agency.
Temple filed a plan of correction in which they promised to educate staff on reporting requirements and to monitor to ensure compliance.
"Education began in March to remind staff to report all patient/family reports of abuse," the plan states.
In the same report, Temple was faulted for failing to take action after the patient who filed the abuse report was described at the time of admission as "disheveled and malodorous."
The report states that despite that observation hospital records "did not contain documented evidence of any assistance provided to the patients for completion of the activities of daily living by nursing staff during the patient's entire admission."
The citation is the second this year for the Temple 198-bed behavioral unit. An earlier report cited the facility for overuse of restraints.
Temple Hospital officials did not immediately respond to requests for comment
Contact: wfrochejr999@gmail

Admissions Halted at TN Nursing Homes


By Walter F. Roche Jr.

Tennessee health officials have ordered a halt to any new admissions and imposed fines following inspections showing evidence of patient abuse, including slapping patients, withholding liquids along with verbal and mental abuse.
Ordered to halt any new admissions were Diversicare of Claiborne and Brookhaven Manor of Kingsport.
A 33-page report on the Claiborne facility cited repeated abuse of some patients by a licensed practical nurse. A certified nursing assistant was cited for slapping a patient.
At the Kingsport facility, state surveyors found that a patient who had violated smoking rules, was ordered out of the facility and taken to a local hotel with just three nights paid for.
The report charges that Brookhaven "placed a resident in an environment that was detrimental to his health. Although the resident had appealed his discharge, he was discharged without his medications for multiple illnesses.
The home was cited for failing to transfer the unnamed resident "to the most appropriate facility or setting to meet his or her need in terms of quality services and location."
A $12,000 fine was imposed against Brookhavem while a $20,000 fine was set for Diversicare.


Wednesday, March 28, 2018

Temple Cited For Restraint Overuse


By Walter F. Roche Jr.

The Temple University Hospital placed patients in the most restrictive of restraints without proper justification, according to an inspection report from the Pennsylvania Health Department.
In a 40-page report just recently made public, surveyors from the state health agency found that staffers at Temple's Episcopal campus "failed to ensure that alternatives to restraints were utilized and proven to be ineffective prior to the application of restraints."
Instead, when state inspectors visited the 198-bed behavioral health facility late last year, they found several patients had been placed in four point restraints, the most restrictive available, without considering less restrictive alternatives.
In addition the report states staffers at the facility failed to remove those restraints in a timely manner and also failed to monitor patients while they were in those restraints.
Asked to comment on the report, Temple spokesmam Jeremy Walter said that the inspectors visited the Episcopal campus as a result of an anonymous complaint.
Although the complaint proved to be unfounded, the inspectors found other issues, Walter said. Stating that those issues were "quickly remedied," he added that "there were no untoward patient outcomes."
Temple also filed a corrective action plan in which it promised to revise policies for the use of restraints,implement an auditing program to ensure it is being followed and educate staff. State officials accepted that plan.
According to the inspection report, the state surveyors found that on Dec. 2 of last year two patients were placed in four point restraints but "there was no evidence" that less restrictive alternatives were considered.
The same was true, according to the report for three other patients placed in four point restraints later in the same month.
In one of those cases, the report states, there was no indication that there was an effort to discontinue the restraints at the "earliest possible time."
Another patient remained in restraints even though he or she was cooperative and had slept for two hours. In yet another case, surveyors found that there was no evidence of compliance with a requirement that there be constant monitoring of patients while being held in restraints.
The facility also was faulted for referring victims of sexual assault to another facility when they were required "at a minimum" to perform a forensic exam and utilize a rape kit.
Contact: wfrochejr999@gmail.com














Tuesday, March 27, 2018

Crozer Burn Unit Cited on Hygiene


By Walter F. Roche Jr.

The burn treatment unit at a Delaware County hospital that bills itself as "a national leader in burn care,"has been cited by state inspectors for failing to follow required infection control practices, including compliance with basic hand hygiene.
In a 39-page report recently made public, the state Health Department also found that for years the hospital has been using the wrong liquid to flush hoses used in the treatment of burn patients.
Since 2006, the report states, hospital staffers have been using chlorhexidine instead of bleach to flush hoses in the hydro therapy room.
Although staffers were required to immediately decontaminate their hands after removing gloves between patient contacts, the state surveyors found that practice was not always followed.
"I witnessed a physician scratch his nose and scalp, put on personal protective equipment and then enter a patient's room," a hospital employee wrote in an email exchange.
The same employee, who was conducting a hygiene compliance audit, wrote that when two residents attempted to follow the doctor into the same patient's room wearing only a gown "I asked them to wash their hands prior to entry and they stated, 'We never had to wash our hands before,'"
Andrew Bastin, a Crozer spokesman, said the facility would be filing a corrective action plan by the April 1 deadline.
"Crozer-Keystone Health System is committed to providing exceptional care with an emphasis on patient safety. Routine inspections from the Pennsylvania Department of Health are a valuable way to identify opportunities for continued improvement," he wrote in an email.
In their report, the state surveyors noted that despite prior internal findings that the expected 100 percent compliance with hand hygiene practices was not being achieved, no action was taken by patient safety and a local governing body.
quality panels established to ensure standards were being met.
"There was no documentation of any actions taken by the local governing body with regard to the staff's failure to meet the benchmark for hand hygiene compliance of 100 per cent," the report states.
In fact the hospital's own audit records showed the hand hygiene compliance rate declined from October of 2016 to October of 2017.
As for the hospital's governing body, the report states that the panel "failed to ensure that the patient's right to care in safe environment was maintained."

Friday, March 23, 2018

Washington County Home Cited, Fined


By Walter F. Roche Jr.


Tennessee health officials have ordered a Washington County nursing home to cease admitting any new patients after state inspectors found multiple violations at the facility.

The order and fines totaling $6,000 against the Family Ministries John M. Reed Center in Limestone were announced today by state Health Commissioner John Dreyzehner. The facility is licensed for 63 beds.

The commissioner said the violations were uncovered in three areas; nursing services, medical records and pharmaceutical services.

In addition he said a state monitor has been appointed to oversee operations at the home.



Tuesday, March 20, 2018

Philadelphia Hospital Cited on Life Safety

By Walter F. Roche Jr.

A major Philadelphia hospital has been cited for multiple deficiencies following a Medicare inspection of fire protection and other building safety requirements.
The four day January review at Pennsylvania Hospital found deficiencies in several buildings including missing fireproofing on structural beams, fire alarms that were partially inoperative and exposed electrical wires.
The 520-bed hospital, part of the University of Pennsylvania Health System, was inspected from Jan. 9 to Jan. 12 for compliance with provisions of the federal Life Safety Code.
Asked for comment, a Penn Medicine spokeswoman said," We worked to correct the items in the report as quickly as possible as well as put alternative protections in place to ensure the safety of all occupants."
She said the state findings "were part of a routine regulatory inspection," adding they were "very common in an active occupied hospital building. At Penn Medicine, patient safety is our number one priority."
Other findings include the failure to maintain the fire resistance rating of common walls and or on stair tower enclosures.
On the sixth floor of one building a door failed to positively latch. In several locations the state inspectors found unsealed penetrations. At another location they found a fire alarm system component with an inoperable component.
A review of fire sprinkler systems found that some gauges had not been serviced within the five year limit. Smoke compartments in some sleeping locations exceeded the maximum area.
According to the report, structural steel in the neurosurgery building lacked fire protection.
Also cited was the fact that the control panel for a fire alarm system in one building was located in a basement under lease by another party, raising concerns about accessibility in the event of an emergency.
In a parallel Medicare review of patient care, inspectors cited the hospital for failure to dispose of expired medications.
Contact: wfrochejr999@gmail.com

Wednesday, February 14, 2018

Two Suicides in Five Days at Belmont


By Walter F. Roche Jr.

Two patients at a Philadelphia behavioral hospital committed suicide in a five day period, according to a court suit and an inspection report by Pennsylvania Health Department.
The deaths on April 24 and April 29 of last year occurred at the Belmont Behavioral Hospital, part of Acadia Healthcare,  a Tennessee based company.
In the April 24 death, which was detailed in a health department inspection report, the patient hung himself in an area that was supposed to be free of fixtures that could be used for ligatures.
The April 29 death involved Jerry W. Gates, 59, a patient who was transferred to Belmont following treatment at a Chester County hospital for dizziness and reporting that "he was hearing voices telling him to harm himself."
The suit charges that despite the diagnosis Belmont determined he "presented a low risk of suicide" and suicide precautions were not provided.
The suit charges Belmont and its parent company Acadia Healthcare with negligence and wrongful death. In a 19-page answer Belmont and Acadia denied any negligence or liability.
The complaint charges that Gates was able to wander from room to room without any supervision and he was not provided with medication for his known insomnia.
 The suit adds that he was found at 4:10 a.m.lying on the floor "bleeding profusely from gaping wounds of the neck caused by a portion of a picture on the wall with which he stabbed his neck.
The suit charges that the facility lacked sufficient and appropriately trained staff.
Acadia, the complaint states, was a direct participant and exercised corporate control over Belmont.
Calling the care provided "a gross deviation from accepted standards of care," the complaint charges the defendants with "flagrant and gross negligence."
In their answer, the defendants acknowledged that Gates was found bleeding from a neck wound. but denied he was found lying on the floor or that he died on the way to a hospital.
"It is specifically denied that Gates was not supervised and was allowed to roam freely without any supervision," the answer states, adding that "all liability against defendants for wrongful death are denied."
As reported previously on this blog, a second suicide at Belmont was detailed in a state inspection report. In that case an unnamed patient hung himself. The state cited Belmont for multiple deficiencies including lack of staff and failure to have facilities designed to prevent suicides.
In fact state inspectors declared a state of imminent danger when they visit in early November of last year.
Contact: wfrochejr999@gmail.com

Monday, February 12, 2018

Philadelphia Hospital Cited In Suicide


By Walter F. Roche Jr.

A Philadelphia behavioral hospital has  been cited in the suicide death of a patient and a host of other violations of state requirements' many involved in the treatment of patients with Electro Convulsive Therapy (ECT) ,in a recently released report..
 The report on the Belmont Behavioral Hospital was first made public without an approved corrective action. The agency normally posts inspection reports only after the submission of an approved plan of correction.
"An approved plan of correction is not on file," the report stated.
Mark Schor, a Belmont official, said the facility did submit a plan of correction and that state officials had accepted it.
The latest version of the inspection report posted today shows that several parts of the corrective action plan have been accepted while others have not.
Schor also said the hospital is in the process of building a 250-bed state-of-the-art replacement facility, scheduled to open in late 2019.
According to the report, based on a Nov. 9 visit to the hospital, inspectors declared a state of immediate jeopardy after discovering numerous violations of anti-ligature requirements, rules set to minimize the risk of suicides.
The failure to comply with those requirements "resulted in the suicide death of one patient," the report states.
The patient was pronounced dead on April 24 of last year.
"The patient was found hanging from a loopable point on a bathroom anti-ligature door," the report states, adding that in addition the hospital failed to request an autopsy report and forms on the disposition of the body were not completed.
The hospital failed to provide a safe setting, the report continues, adding that a hospital psychiatrist "did not document the observations and special precautions" needed for the patient.
The facility did immediately change its policy to require that all patients with a suicidal risk be observed by staff every seven minutes. As a result the state of immediate jeopardy declared at 12:14 p.m., on Nov. 9 of last year was lifted at 7:46 p.m.
In its corrective action plan Belmont said they had designated a patient safety officer and that policies and  procures for ECT treatment were reviewed and revised.
Belmont is part of the Acadia Health Care LLC, a company that operates some 579 treatment facilities.
Other findings by the state Health Department surveyors included the failure to properly monitor patients who had undergone ECTs. During the visit two patients were observed in the treatment area without any staff present.
Still other violations included medication carts left unlocked and unattended and failure to maintain complete records showing how many vials were used on ECT patients. There was "no documented evidence of how many vials were delivered to the ECT room," the report states.
Inspectors also cited failure to respond to grievances within a seven day limit and failure to secure patient records to ensure confidentiality. They observed 166-pages of patient related data in open view.
Inspectors also said Belmont "failed to ensure a sufficient number of nursing staff were available to meet the nursing needs of the patients."
Contact: wfrochejr@gmail.com




Friday, January 19, 2018

Einstein Inspection Report Finally Posted

By Walter F. Roche Jr.

More than six months after a critical inspection, state officials have finally made public a trimmed down hospital inspection report that omits multiple details included in a prior version which state officials now say had been briefly but mistakenly made public.
The now official report on a three day May inspection at the Albert Einstein Medical Center cites the
701 bed facility for failure to properly analyze and implement preventative actions after four patients experienced adverse events.
"The  hospital must measure, analyze and track adverse patient events," the report states.
The official report provides details on two of the cases which resulted in deaths. Details of two other deaths included in a prior version of the report are not included in the official report.
April Hutcheson, spokeswoman for the Pennsylvania Health Department, said the initial report was "not completed and unintentionally posted."
"The report on the site now is correct," she added.
She declined to answer questions about details included in the initial report but omitted from the now official report.
Einstein officials did not respond to requests for comment but the facility did submit a corrective action plan to the state including updating procedures for responding to adverse events. The hospital, however, said it disputed the state's right to access certain internal documents relating to the cases.
The two cases detailed in the official report include a patient admitted to the facility on Aug. 3, 2016 "looking pale and unresponsive." A subsequent entry stated the patient later died from "excessive sedation leading to hypo-ventilation and brain anoxia."
The second case detailed in the final report involved a patient who underwent a colonoscopy on September of 2016 and left "against medical advice."
The patient, according to the report, returned the next day with worsening abdominal pain and eventually passed away.
The report cites Einstein for failing to conduct a root cause analysis, a process designed to find the root cause of an error, on the two cases.
Omitted from the final report were details of the other two cases. One involved a patient who choked on a sandwich and the other a patient who was injured during an esophageal in-tubation.
Both the final and initial reports cited Einstein for refusing to allow state inspectors to interview staff involved in one of the cited cases.
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