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.
Monday, April 16, 2018
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."
Monday, April 9, 2018
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
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.