Tuesday, August 14, 2018
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."
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.
Wednesday, August 8, 2018
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.