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.
Contact: wfrochejr999@gmail.com

No comments:

Post a Comment