Friday, December 28, 2018

Hospital Handcuffed Patients


By Walter F. Roche Jr.

A Pennsylvania hospital placed three patients in handcuffs without a physician's orders, a state health investigation has shown.
The Oct. 26 report issued by the state Health Department concluded that the Washington Hospital in Washington County had violated laws and regulations protecting patients' rights.
"Significant corrections evidencing compliance will be required," the report states.
A review of patients' records showed five patients were placed in restraints without first considering whether less restrictive interventions could have been applied.
In addition to the three placed in handcuffs, the records showed two others were placed in restraints without consideration of less restrictive measures.
"The facility failed to ensure restraints would only be imposed to ensure the immediate safety of the patients, a staff member or for others," the report states.
In a plan of correction, the hospital said that in the future handcuffs would not be used unless the patient is in the presence of a police officer.
One of the cases cited was a 66-year-old male patient suffering acute alcohol withdrawal who was handcuffed "as a result of threatening staff.
A 52-year-old male admitted for a mental health evaluation was handcuffed "as a result of assaulting staff."
The third case was a 41-year-old male who was brought in by a police officer who had placed him in handcuffs.
A staffer told the state surveyors that when police bring a handcuffed patient to the hospital "we switch handcuffs and they stay on until the doctor gives an order to release them."
In the plan of correction the hospital stated that in the future handcuffs will not be used until a physician assesses the patient.
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Hospital Failed to Probe 4 Abuse Cases


By Walter F. Roche Jr.

A 590-bed Pennsylvania hospital failed to properly investigate four separate cases of suspected abuse, according to a report issued by the state Health Department.
The report on the Lancaster General Hospital, part of Penn Health, resulted in state surveyors declaring a state of immediate jeopardy, forcing hospital officials to come up with an immediate plan to eliminate the risks faced by patients.
The hospital "failed to ensure a comprehensive investigation of allegations of abuse. This failure placed patients who alleged the abuse and other patients that may have had contact with the staff member in question at risk," the report dated Nov. 14 states.
The inspectors also cited the hospital for failing to report the suspected abuse to police and other state agencies.
The hospital filed a plan of correction in which it promised to educate employees on abuse reporting requirements and to set up a dedicated phone line for reporting such allegations.
In one of the four incidents a patient reported awakening to discover a hospital employee "touching the patient's genitals while touching the employee's own genitals."
The hospital eventually concluded the report was unfounded and took no further action.
In a second incident a patient reported that an employee fondled "the genitals for five to 10 minutes while applying topical medication to a rash."
In the third incident a patient reported being grabbed by a nurse while waiting for an elevator. The patient, the report states, "was upset that a nurse put hands on the patient in a rough manner."
The fourth incident involved a patient who was struck by his wife, but the patient was able to free himself.
The surveyors faulted the hospital for failing to report the incidents to the proper authorities including the Adult Services Hotline. the Department of Human Services and local police.
The surveyors found that the employee who was involved in the first incident was allowed to return to work even though the allegation was not fully investigated.
John Lines, a hospital spokesman, said that the employee remains on administrative leave while the police investigation continues
The report also states that hospital records show no documentation that the there was any follow up with the patient making the allegation.
The report on Lancaster General was the second in recent months in which state surveyors faulted health administrators for failing to properly investigate allegations of sexual abuse. The other report was issued on the Lifecare Behavioral Hospital where two allegations of sexual abuse against the same employee were not fully investigated.
The employee had returned to work when he was arrested by police.
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Thursday, December 27, 2018

Geisinger Delayed Care for Insurance Check


By Walter F.Roche Jr.

The Geisinger Community Medical Center violated a federal law when it delayed care to a half dozen patients to get pre-authorization from their insurance carriers.
Surveyors from the state Health Department concluded that the delays in care at the 273 bed Scranton facility violated the Emergency Medical Treatment and Active Labor Act.
The inspection, the result of an unannounced on site November visit, found that in six of 20 cases reviewed, care was delayed by up to a full day awaiting pre-authorization from the individual insurance carriers. The six were seeking admittance to the hospital's behavioral health unit from referring hospitals.
"A participating hospital may not delay providing appropriate medical screening," the report states, "in order to inquire about the individual's method of payment or insurance status."
The report notes that the law does not bar health facilities from following reasonable registration procedures as long as those procedures do not "unduly discourage individuals from remaining for further evaluation."
Three of the six required specialized psychiatric care, according to the report.
In at least two of the cases reviewed, admission was delayed for a full day awaiting insurance carrier approval.
The hospital filed a plan of correction including a re-education program for emergency room staffers and an audit system to assure compliance. A hospital spokesman said the facility amended its procedures for handling transfers from other facilities thus avoiding any delays in care.
"We’ve taken steps to rectify that issue, which was related to patient transfers from outside facilities. We have amended our registration process for accepting transferring patients to reduce the risk of delaying treatment, and continue to work with the Department of Health to ensure our compliance with such requirements," the spokesman wrote in an email response to questions.


The hospital also revised its patient intake forms to eliminate the section requiring insurance coverage information.
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Hospital Failed to Probe Abuse Complaint



By Walter F. Roche Jr.

A Pittsburgh behavioral hospital reinstated an employee who was still under investigation for sexual abuse of a patient, according to a report from the Pennsylvania Health Department.
The worker at the 49 bed Lifecare Behavioral Hospital was finally terminated after his arrest at the facility in October, according to a recently released report.
State inspectors, who were sent to the facility in response to a complaint, concluded that the hospital failed to properly investigate two separate complaints on the same unidentified staffer.
Records reviewed by the state surveyors showed one of the victims stated that the worker came into her room and said, "Let me rub your back."
She said she got nervous, got out of bed and started to walk out of the room. She said she told him she didn't need a back rub.
The first complaint against the employee was based on an incident that occurred between April and July.
A second complaint against the same employee for inappropriate touching was filed on Aug. 14, according to the report. He was suspended, but then reinstated on Sept. 10 when hospital officials concluded the complaint was unfounded.
The facility "reinstated the employee on Sept.10 absolving him of any wrongdoing regarding the Aug. 14 incident," the report states, "despite the employee remaining a suspect for the earlier incident."
The employee was at work at the facility on Oct.16 when police placed him under arrest.
The hospital filed a plan of correction in which it said workers would be retrained on the correct procedures to follow in response to a report of sexual abuse. The plan also calls for increased use of surveillance cameras and monitoring of employee activities.
Hospital officials also stated that they were asked by police not to immediately investigate the initial report.
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Wednesday, December 26, 2018

State Hospital Hit for Suicide Risks


By Walter F. Roche Jr.


A Medicare inspection of a Pennsylvania state mental hospital turned up multiple risks for patients with suicidal thoughts.
The October review of the Clarks Summit State Hospital found that electric beds with side rails in multiple patient rooms contained open loopable points that "pose a risk for a person with suicidal thoughts."
The beds were found in some 15 locations.
A plan of correction filed by hospital officials calls for the side rails to be removed and safely stored away from areas accessible to patients. Patients still requiring side rails will be monitored with checks by staffers very 15 minutes.
The inspection was made as part of the annual re-certification process for participation in the federally funded Medicare and Medicaid programs.
The same report cites the hospital's dietary department for staffers not wearing nets over facial hair and for the failure to record temperatures of foods being served to patients. The department also was cited for making unapproved menu substitutions.

Tuesday, December 18, 2018

Phila. Behavioral Hospital Cited in Assaults


By Walter F. Roche Jr.

A Philadelphia behavioral hospital caring for elderly patients has been cited for failing to act when an employee was accused of sexually assaulting two patients.
Haven Behavioral Hospital, a 36-bed facility on Henry Ave, was the subject of an October inspection report by state Health Department surveyors who found that the employee accused of the assaults was still working at the hospital despite two separate incidents.
The hospital "failed to immediately report and investigate when one patient reported allegations of sexual abuse and suspicious behavior by the same (*alleged) employee that involved another patient," the report states.
"The employee remained on duty and provided patient care the night the allegation was reported," the report states.
Hospital officials could not be reached for comment. They did submit a plan of correction promising to re-educate employees on the requirements for reporting suspected abuse. The plan also calls for audits to assure continuing compliance.
The report also cites discrepancies in the accounts of the two incidents based on interviews and reviews of patient records.
"There was no documentation the facility reported or investigated these allegations," the report states.
Inspectors found the employee was still working though the two incidents occurred months earlier.
They declared a state of immediate jeopardy until the hospital came up with an action plan calling for the immediate termination of the employee, confiscation of his keys and alerting security personnel to bar the employee from entering the building.
The state of immediate jeopardy was reinstated the next day when inspectors learned the action plan hadn't been implemented and hospital officials hadn't even contacted the suspect.
He was finally terminated on Oct. 11, according to the report.
The first incident was on April 18 when the employee was discovered in a locked patient's room "longer than expected."
"Patient was talking and moaning," the report states.
An employee told surveyors the incident was not immediately reported "because the co-worker(witness) was afraid of how the suspect would react," describing him "as a larger person and she was afraid he would become angry."
On April 30 a second incident was reported.
"This was the second allegation of possible sexual assault that involved (the suspect}and this was documented in the witness statement submitted on April 30," according to the report.
Other deficiencies cited during the October visit included failure to perform annual performance evaluations and improper behavior by staffers when they got into an argument with each other.
Surveyors also found patients at risk for suicide had access to areas where ligatures could be utilized.
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Monday, December 10, 2018

PA Veterans Home In Repeat Violations


By Walter F. Roche Jr.

A state run facility for veterans with a history of care problems has been cited yet again and for many of the same violations cited previously but apparently never corrected.
The lengthy report on the Hollidaysburg Veterans Home was the result of an annual Medicare/Medicaid re-certification inspection by the state Health Department in late October. The 257-bed Blair County facility, the report states, "failed to correct past deficiencies."
Among those repeat deficiencies were failure to ensure a safe environment and multiple failures to keep and maintain required medical records. Those same deficiencies were cited in the last survey conducted on Dec. 15, 2017.
Data required to be collected and filed on each patient within two weeks was delayed by up to 63 days for nine of 66 residents, the report states.
In one resident's record inspectors noted conflicting information on the presence of a catheter. One entry said the patient was "voiding well," while another showed he had to be rushed to an emergency room because he hadn't voided for 11.5 hours. The catheter was then re-inserted.
The surveyors concluded the physician's "voiding well" notes were inaccurate.
Other items included the lack of documentation that narcotics distributed for patients were actually administered. In another medication error a drug was administered to a patient by the wrong nurse.
Another patient was injured when staffers failed to check the latches on the hoist before lifting her from her bed. The home was also cited for failing to properly investigate the incident.
The surveyors found that the records of three residents showed a required care plan had not been prepared.
A deaf resident was observed by surveyors on several occasions without his hearing aid. They reported that a staffer later acknowledged that she hadn't finished cleaning it for the patient.
Another resident reported to a surveyor that she hadn't gotten a scheduled shower.
A resident with a urinary infection, the report states, had been prescribed a drug that subsequent test results showed would be ineffective. Nonetheless the prescribing urologist hadn't been advised of the need for a new prescription, the report states.
The medication, the surveyors reported, was needed before planned surgery.
Two other patients, the report states, had untreated pressure ulcers while another was not getting sufficient pain medication.
As it had following the last inspection, Hollidaysburg officials filed a plan of correction in which they promised to correct the deficiencies and to attain compliance by conducting a series of audits to maintain compliance. The plan also calls for a quality improvement committee to focus efforts on maintaining compliance.
The inspection report, however, states that the same committee "failed to correct quality deficiencies to ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
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Tuesday, December 4, 2018

Einstein Cited in Patient Discharge


By Walter F. Roche Jr.

A major Philadelphia hospital has been cited for discharging a patient to a nursing home that refused admission apparently because of the lack of planning or records for the patient.
The patient was taken by an ambulance driver on Aug. 22 to the Harborview Rehabilitation and Care Center in Doylestown.
"Harborview did not accept the patient when arrived," the report states.
"The hospital must transfer or refer patients, along with the necessary medical information to appropriate facilities, agencies or outpatient services as needed for follow up or ancillary care," the report states.
Records reviewed by state surveyors showed the patient was apparently supposed to be released to Willow Terrace, a Philadelphia nursing home.
"Employee 8 confirmed the patient was transferred to the wrong facility and refused admission on arrival," the report states.
According to the report the ambulance driver was then instructed to take the patient to the "closest emergency department for care and treatment."
Einstein officials did not respond to requests for comment.
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Sunday, December 2, 2018

Life Safety Violations at Brooke Glen Behavioral


By Walter F. Roche Jr.

A Montgomery County behavioral hospital has been cited by state health surveyors for violations of the federal Life Safety Code.
The Brooke Glen Behavioral Hospital, part of the Universal Health Services group, was inspected in October. The deficiencies include unsealed mortar joints above a suspended ceiling and a missing sprinkler escutcheon.
Inspectors also found that the 146 bed hospital "failed to maintain heating, ventilation and air conditioning effective for the entire facility."
A junction box was missing a cover plate and the space between and a door frame was too wide. Three doorways were obstructed.
The hospital was also cited in a separate inspection for failing to discard an outdated anti-psychotic drug.
There was no plan of correction filed in response to the life safety report.
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