Wednesday, October 31, 2018

Two Patients Injected with Outdated Drug


By Walter F. Roche Jr.

Two patients at a rural Pennsylvania hospital were injected with outdated drugs on the same day despite a warning from another staffer that use of the outdated product could put patients at risk for infections or other adverse effects.
The report on the 70 bed Clarion Hospital in Western Pennsylvania also cites the facility for having outdated medicines and supplies in a crash cart in the hospital's cancer center and for having injections "administered by unqualified personnel."
The report followed a June 28 visit to the hospital which was described as an "unannounced onsite complaint investigation."
Clarion Hospital officials did not respond to a request for comment on the incidents which occurred in January. They did file a plan of correction with the state.
The state inspectors expressed concern that neither of the patients had been informed of the missteps.
"We cannot provide evidence that either patient was notified," the report states.
A patient, the report continues, should be notified that he received a potentially contaminated medication and education to be provided on monitoring for infection."
"When asked why patients had not been notified, Employee Three was unable to provide an answer," the report continues.
Surveyors also asked why the incident had not even been discussed by the hospital's patient safety committee. They were told,"We thought that it wasn't a serious event."
A review of hospital records showed the label on the vial of testosterone stated it was not to be used after Jan. 3, 2018.
The shots, the report states, were administered on Jan.10 and Jan. 24, more than 20 days after the vial should have been discarded.
Hospital records showed the injections were administered by a "medical assistant" despite a requirement for injections to be given by a registered nurse or practical nurse.
The hospital in its response said medical assistants would no longer be allowed to administer injections. In addition the staffer who gave the shots, despite the warning, is no longer employed at the hospital, the report states.
"The practice of medical assistants administering medications at hospital-based clinics was ceased during the survey on June 28, 2018," the plan of correction states.
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Monday, October 22, 2018

3rd St. Luke's Facility Cited


By Walter F. Roche Jr.

An Easton hospital has been cited for violating state and federal regulations when the same syringe was mistakenly used on two different patients on the same day instead of being discarded after a single use.
The recently released report from the Pennsylvania Health Department states that on June 5 two patients at St. Luke's Hospital in Northampton County were injected with the same syringe when they were undergoing a gastrointestinal procedure.
St. Luke's Anderson campus, a 108-bed facility, is the third facility in the Saint Luke's University Health Network to be cited by the state health agency in recent weeks. Health system officials did not respond to requests for comment on either report.
According to the latest report a syringe of propofol was refilled after being used on one patient and then used by another anesthesia provider on a second patient.
"We had a medication error in the GI lab," the report quotes from hospital records. "We had one provider who never refills a propofol syringe and one who does.
"The one relieving assumed that the full propofol must be clean," the report states, adding that the assumption was wrong.
"It was used and refilled," the report states.
The facility was also cited for failing to notify family members when patients were admitted and failure to comply with restrictions on the use of restraints.
In a plan of correction filed with the state, the hospital said it would institute a re-education program to ensure that syringes will be discarded after a single use. An audit system will also be implemented to ensure compliance, the corrective action plan states.
In another recent report two Saint Luke's facilities in Carbon County were cited for failing to implement a plan of correction issued in response to an earlier critical report. Deficiencies included failure to remove items that could be used by patients to commit suicide.
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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.
Contact: wfrochejr999@gmail.com

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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