Monday, November 19, 2018

Indiana Regional Cited in Patient IV


By Walter F. Roche Jr.

A staffer at the Indiana Regional Medical Center placed an intravenous needle in a patient's extremity ignoring a bracelet warning against using that site for an IV. Then the unnamed staffer apparently removed the warning bracelet.
That was the conclusion of a state Health Department inspection report on the 164-bed health facility just made public.
The Sept. 7 visit to the hospital was labeled an "unannounced on-site complaint investigation."
The hospital, which did not respond to a request for comment, was also cited for failing to properly report the event which ocurred in June. The hospital is part of the 18 member Pennsylvania Mountains Healthcare Alliance.
According to the report, other employees reported seeing a staffer attempting unsuccessfully to insert the IV in the correct extremity on the evening of June 20. The next morning, June 21, an employee noticed that the IV was in the wrong extremity and the warning bracelet had been removed.
The facility "failed to ensure that an intravenous device was not inserted into an extremity which was restricted from use," the report states, adding that the hospital also "failed to ensure that the warning bracelet was maintained."
The inspection report notes that such restrictions are required when a patient has undergone a mastectomy or suffered paralysis in the extremity.
The staffer who noticed the wrongly placed IV immediately removed it, the report states.
In a plan of correction filed with the state, Indiana Regional promised to implement a retraining program and audit cases in which an extremity restriction was in place.
The plan does not indicate what if any action was taken against the employee who placed the IV in a restricted extremity or whether the patient suffered any adverse effects.
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Thursday, November 15, 2018

UPMC Unit Faulted in Suicide


By Walter F. Roche Jr.

Pennsylvania health official have concluded that the Sunbury Community Hospital, part of the UPMC health group, failed to follow its own policies when it allowed a suicidal patient to walk out the door without proper intervention.
The incident, which apparently ended in the patient's demise, was described in a report from the state Health Department recently made public.
According to the report a patient with a history of suicide attempts came to the 106-bed Northumberland County facility on Aug. 30 at 3:17 p.m.
UPMC officials did not respond to a request for comment.
The patient, the report states, "was at heightened risk" of self harm based on the medical record. After donning paper scrubs the patient reported back pain at 4:10 p.m. and asked for a pain pill. The patient walked out of the facility at 6:10 p.m. after requesting and getting back clothing.
The surveyors found that hospital staffers failed to notify the physician that the patient was leaving until after the deparureand there was no record of the patient being counseled about the risks of leaving against medical advice. Nor the, report states, did the record report the patient's reason for leaving.
The physician had stated that it was not safe for the patient to be left alone and had ordered checks every 15 minutes.
There was also no record of attempts to convince the patient not to leave or to give formal consent to departing against medical advice. Also absent was any record of a staff witness to the events.
The report states that a hospital employee called state police on Sept. 6 to confirm the patient's death.
The incident showed a failure for the facility to follow its own policies related to the care of patients who leave against medical advice,the report states.
Contact: wfrochejr999@gmail.com

Monday, November 12, 2018

PA Hospital Hit for Staff Shortages


By Walter F. Roche Jr.

A state report on a 412-bed Pennsylvania hospital has concluded that staff shortages at the facility have jeopardized patient care and caused serious injuries to at least two patients.
The detailed report on the Wilkes Barre General Hospital comes just months after nurses at the chain owned hospital went on strike.
The report, issued recently by the state Health Department, was the result of a complaint investigation, and followed an on site visit by state surveyors from Sept. 10-14.
The hospital is owned by the Tennessee based Community Health Associates. The for-profit firm last year sold off four of its Pennsylvania properties including the Chestnut Hill Hospital in Philadelphia.
Hospital officials did not respond to requests for comment.
According to the inspection report staffing levels at the Wilkes Barre hospital fell below expected levels for 81 of 148 shifts reviewed. In addition 91 registered nursing positions were unfilled.
It was a lack of staffing, the surveyors concluded, that enabled two suicidal patients, who were supposed to be on constant one-to-one watch, to injure themselves.
One patient, who was not properly monitored, had hidden a razor in his mouth and was discovered with multiple open lacerations on his arms and neck, some requiring sutures.
"The facility failed to prevent self harm of suicidal patients," the report states.
Surveyors found that although a doctor had ordered that the patient have "direct observation at all times" shortly after admission on Aug. 11, no sitter was available.
A little over an hour after admission the patient was found with the lacerations.
The surveyors found that although the hospital had purchased a high tech metal detector, it had been placed in storage because there was insufficient staff to operate it. Instead the patient was checked with a wand that failed to detect the razor.
After the wounds were discovered, the patient, at the request of a staffer, removed the razor from the mouth and handed it to the nurse.
The second patient was admitted on Sept. 13 at 1 a.m. and a doctor also ordered "direct observation at all times." The patient went un-watched and was discovered hypoxic and non-responsive later on the same day. The report states that the patient used gown strings for self strangulation.
The patient was bagged and regained consciousness, surveyors reported.
"Nursing documentation revealed there was no sitter at the bedside due to lack of staffing," the report states.
The facility also was faulted for failing to remove restraints on the same patient on a timely basis or for proper monitoring while the restraints were in place.
A review of the records of four other suicidal patients showed three of the four went without sitters, despite physicians' orders.e
As for staffing in general the inspectors found that the facility failed to provide organized nursing services 24 hours a day.
"The chief nursing officer and assistant chief failed to provide oversight," the report states.
The lack of staffing also was blamed for delays in delivering patient medications in two of three cases reviewed.
A staffer told the inspectors there was insufficient staff to turn patients or care for patients properly.
The staffing was unsafe for patients and staff, one employee reported, adding,"The patients on our unit are very sick and this is not fair to them."
This is the worst they've ever seen it and morale is down, the surveyors related.
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