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.