Tuesday, December 31, 2019

UPMC Cited for Withholding Records


By Walter F. Roche Jr.

A UPMC facility has been cited for refusing to provide to state surveyors the minutes of meetings of an internal committee established to set and review professional improvement efforts.
Officials of UPMC Somerset told the state Health Department surveyors during a recent visit that they could not review minutes of the committee meetings because they were "peer review protected."
"On November 1, 2019 at approximately 1:00 p.m., multiple requests were made to EMP10 and EMP11, to review the Professional Improvement Committee meeting minutes, in order to evaluate the function and process of the committee. The request was denied," the report states.
In a plan of correction hospital officials said that in the future surveyors will be allowed to review the committee minutes but will not be allowed to take copies from the facility.
The citation marks the second time in recent months that state health surveyors have been rebuffed when they asked for such records. The Guthrie Towanda Memorial Hospital was cited for the same deficiency following a June visit to the facility.
The 99-bed UPMC hospital also was cited for failure to obtain properly executed consent forms from patients undergoing surgical procedures.
In one case an additional surgical procedure was performed that had not been included in the consent form.
In another case a patient undergoing an appendectomy had been anesthetized, but the surgeon canceled the procedure because it had not been approved by the patient's insurance carrier.
UPMC officials did not respond to requests for comment.
Contact: wfroche999@gmail.com

Monday, December 30, 2019

Hospital Cited for "Serious Events"


By Walter F. Roche Jr.

A small rural Pennsylvania hospital has been cited for failing to promptly and properly report serious events involving the care provided to three separate patients.
The recently released report cites the Endless Mountains Health System in Montrose for failing to report serious events to the state Health Department and the Patient Safety Reporting System. Hospital officials told state surveyors that their colleagues didn't think the incidents met the definition of a serious event.
The surveyors were at the hospital to determine whether it complied with the minimum standards for participation in the federally funded Medicare and Medicaid programs.
According to the report a serious event is "an event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient."
Loren Stone, chief executive officer for the health system said, the cases cited by the state Health Department, were, in fact, submitted correctly under the criteria set by the state Patient Safety Authority.
"Endless Mountain Health maintains that they were correctly classified under the Patient Safety Authority guidance and algorithm," he wrote in an email response to questions.
The first case cited in the state report was that of a patient who underwent a CAT scan with a contrast agent. The patient suffered a rash over the entire body due to an allergic reaction to the contrast and had to be treated with Benadryl and other drugs.
The second patient was in the facility for hysterectomy but had to be returned to the operating room due to post-operative bleeding.
The third case involved a patient who was treated for severe pain with a morphine drip. The patient began shaking within 10 minutes of the treatment and was treated with Benadryl and Pepcid.
The hospital filed a plan of correction in which it promised to re-train staff on what constitutes a serious event. The plan also calls for an auditing system to monitor all incidents to ensure they are being properly reported.
The report also faults the hospital for failing to perform annual performance reviews on three certified nurse anesthetists.
In addition a review of records showed staffers failed to perform pain assessments on five patients following the administration of pain medications and before their discharge.
Stone said that the hospital submitted a plan of correction that had been accepted and implemented.
In a final item the state surveyors faulted the hospital for the failure of a member to attend a meeting of the infection control committee. The same finding was included in a prior report on the same facility.
Contact: wfrochejr999@gmail.com

Thursday, December 19, 2019

Antibiotic Delayed, Resident Dies


By Walter F. Roche Jr.

Health care workers at a Tennessee assisted living facility failed to administer a prescribed antibiotic to a resident for four days and she died days later with a massive infection, according to a report from the state Health Department.
The details of the 87-year old woman's illness and subsequent death were included in a 15-page report on Morningside of Paris, an 84 unit assisted living facility. As a result of the Nov. 6 inspection state Health Commissioner Lisa Piercey imposed a freeze on any new admissions to the facility.
Morningside officials did not dispute the state action and said they were working with health officials to correct any deficiencies
The inspection report also questions the handling of the resident, identified only as Resident 12, and her death certificate after she was found unresponsive on Oct. 22.
"Resident 12 was not pronounced deceased by a qualified individual," the report states, noting that the death certificate was not signed until a week after the patient's death, well beyond the 48-hour required limit.
Resident 12 was admitted to a secure unit in the facility on May 3, 2016 and had multiple conditions including schizophrenia, dementia and Alzheimer's disease, records showed.
A review of patient records showed the resident was seen on Oct. 11 for a possible eye infection. A sample collected on that date also showed she had escherichia coli in her urine, which the report noted can result in death if left untreated.
A prescription for an antibiotic was ordered, ampicillin two times a day, the report states. But her first dose of the antibiotic was not administered until 6 p.m. on Oct. 15, when a new prescription was issued by the family nurse practitioner overseeing the resident's care.
Subsequently, the records show, the facility staff learned that the original Oct. 11 prescription had been sent to the wrong address.
When state investigators questioned the nurse practitioner she said she was unaware the drugs had been sent to the wrong address.
The nurse practitioner did say that she had given the patient another antibiotic by injection, although the required documentation was not on file at the facility. The nurse told state surveyors that the documentation was on file at her location.
As for the death certificate, the report questions whether the physician who signed the document had ever even seen or treated the patient.
"There was no documentation Physician 1 had treated, assessed or examined Resident 12 at any time prior to the resident's death," the report states.
Though the death certificate lists sepsis as a contributing cause, it lists medullary failure as the cause of death. The nurse practitioner said she was not aware of the documented cause of death on the death certificate and was "not familiar with that term."
Morningside issued a response to the report stating," We are committed to maintaining a safe and comfortable community," adding that they were working with state health officials to correct and deficiencies.
"In the interim we continue to operate as usual providing outstanding care to facility residents," the statement concluded.


Wednesday, December 18, 2019

Coatesville VA Faulted in Audit


By Walter F. Roche Jr.

An emergency care unit at the Coatesville PA. Veterans Affairs Medical Center was understaffed and out of compliance with minimum VA requirements, according to a report from the VA Inspector General.
The 69-page review issued Wednesday concluded that the lack of staffing and other resources could lead to potentially unsafe situations.
Stating that the facility was required to provide access to appropriate and timely emergency care 24 hours a day, the report found that the facility administrators had failed to obtain a waiver in order to provide round the clock service. Although the leadership was aware of the need for a waiver a preliminary request for a waiver was not submitted until February of this year.
The report noted that no action had been taken on the request.
VA Coatesville officials did not dispute the finding or other deficiencies and submitted a corrective action plan that will gradually reduce the hours of operation for the urgent care unit. Eventually the unit will close at 5 p.m. every day, according to the report.
Other findings include the failure to have two registered nurses on duty 24-hours a day. Citing the fact that the lone remaining nurse from 7 p.m. to 8 a.m. could be called away in an emergency, the report states, "this could result in potentially unsafe situations"in the urgent care center.
The report stated that local VA officials were aware of the requirement for two nurses but did nothing to correct the situation.
The auditors also noted that the emergency unit did not have round-the-clock access to laboratory, pharmacy and radiology services.
"This resulted in delays and inconsistent delivery of care," according to the report.
The auditors also faulted medical center officials for using a VA ambulance to bring patients who experienced a medical emergency while on the facility grounds.
The patients should have been taken to a local emergency room, the report states.
Other deficiencies cited in the report were problems with staff privileging, lack of military sexual trauma training, lack of environmental cleanliness and lack of adequate emergency generator testing.
Contact: wfrochejr999@gmail.com

Saturday, December 14, 2019

PR Touts New Transplant Program


By Walter F. Roche Jr.

Tower Health and its Reading Hospital have launched an extensive public relations campaign to tout their new transplant program, but officials of the health company have refused to answer a series of questions about the program.
Tower announced on Sept. 12 that it would be taking over the transplant program formerly based at the now shuttered Hahnemann University Hospital.
"Thousands of transplants and we're just beginning," proclaims one ongoing Tower television commercial.
In one recent press release the health care firm boasted of the approval of its new transplant institute by regulatory agencies, the United Network for Organ Sharing (UNOS) and the Department of Health.
"The approvals from UNOS and the Department of Health is fantastic news for Tower Health, our patients, and the community," said Clint Matthews, Tower President and CEO, in the Nov.22 press release.
While officials of UNOS confirmed approval of Tower's kidney and liver programs, state Health Department officials did not.
Nate Wardle, a Health Department spokesman, said the agency was informed of Tower Health's plan to initiate a transplant program.
"We will conduct surveys as they go through this process, but the Centers for Medicare and Medicaid Services (CMS) will make the final determination of when the program is approved," Wardle wrote in an email response to questions.
CMS oficials, meanwhile, said they could not comment on any pending applications. Under recent federal rules changes, however, hospitals seeking approval for a transplant program must first seek state approval.
Anne Paschke of UNOS wrote in an email that Reading Hospital has been approved for kidney, living kidney and liver transplantation. She added that their records indicate the program was already in operation.
Among the questions posed to Tower and Reading that went unanswered was whether Tower received bankruptcy court approval to take over the program and whether Tower made any payments into the bankruptcy in return for the program takeover.

















Published on November 22, 2019
Tower Health Transplant Institute Receives Regulatory Approvals

West Reading, PA., November 22, 2019 - Tower Health announced today that Tower Health Transplant Institute has received the necessary regulatory approvals from UNOS (United Network for Organ Sharing) and the Department of Health to begin performing transplant surgeries.

"The approvals from UNOS and the Department of Health is fantastic news for Tower Health, our patients, and the community," said Clint Matthews, President and CEO, Tower Health. "We are honored to bring this award-winning team and its renowned physicians and staff to the communities we serve. It is a true display of the relentless pursuit of excellence in all that we do."

The Tower Health Transplant Institute and Center for Liver Diseases includes transplant surgery, hepatology, and nephrology inpatient services at Reading Hospital, selected inpatient services at Chestnut Hill Hospital, and outpatient services at Reading Hospital and in Center City Philadelphia. The team will perform kidney and liver transplants at the Reading Hospital HealthPlex, preserving a leading transplant program for southeastern PA and bringing kidney and liver transplant services to Berks County and its surrounding communities for the first time.

"We are thrilled to have the transplant program, and all that it brings to our patients and communities, be part of Tower Health," said David Reich, MD, Medical Director and Chief Surgeon, Tower Health Transplant Institute. "This is an extraordinary way for us to deliver on our promise of Advancing Health. Transforming Lives."
About Tower Health

With more than 12,000 team members, Tower Health consists of Reading Hospital in West Reading; Brandywine Hospital in Coatesville; Chestnut Hill Hospital in Philadelphia; Jennersville Hospital in West Grove; Phoenixville Hospital in Phoenixville; and Pottstown Hospital in Pottstown. It also includes Reading Hospital Rehabilitation at Wyomissing; Reading Hospital School of Health Sciences in West Reading; home healthcare services provided by Tower Health at Home; and a network of 22 urgent care facilities across the Tower Health service area. Tower Health offers a connected network of 2,000 physicians, specialists and providers across 125 convenient locations. For more information, visit towerhealth.org.



Tower Health Recruits Nationally Recognized Kidney and Liver Transplant Team; Opens Tower Health Transplant Institute
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Published on September 12, 2019
Tower Health Recruits Nationally Recognized Kidney and Liver Transplant Team; Opens Tower Health Transplant Institute

Tower Health announced today that a new Tower Health Transplant Institute has been organized and will become the new home for the nationally recognized kidney and liver transplant program formerly located at Hahnemann University Hospital.

The program's team of renowned surgeons, hepatologists, and nephrologists have joined the Tower Health Medical Group and will provide services in West Reading and Philadelphia. The transplant team surgeons -- who have performed more than 3,000 organ transplants -- will perform kidney and liver transplants at the state-of-the-art Reading Hospital HealthPlex, one of the most technologically advanced surgical facilities in the state. Inpatient services will be provided at Tower Health - Reading Hospital and Tower Health - Chestnut Hill Hospital, with outpatient services at Reading Hospital and in Center City Philadelphia. The Tower Health Transplant Institute will also include the Center for Liver Disease that was part of the Hahnemann program.

"With the unfortunate closure of Hahnemann, our goal was to create a home for this nationally-ranked kidney and liver transplant program so it could continue serving patients in eastern Pennsylvania and surroundings areas," said Clint Matthews, president and CEO of Tower Health. "We are pleased to welcome these ten outstanding surgeons and physicians, along with experienced clinical and support staff. These specialists chose to come to Tower Health because they liked what they saw in our people, our facilities, and our vision."

While at Hahnemann, the Transplant program became the only 5-star-rated kidney transplant program in Pennsylvania and the third best kidney transplant program in the nation as ranked by the Scientific Registry of Transplant Recipients, based on patient survival with a functioning kidney one year after transplant. Tower Health - Reading Hospital, where transplants will take place, is the largest hospital between Philadelphia and Pittsburgh and is recognized nationally for its exceptional clinical quality and safety, advanced technology, and compassionate care.

David J. Reich, MD, Medical Director of the Tower Health Transplant Institute and Professor of Surgery at Drexel University College of Medicine, noted that "along with internationally distinguished hepatologist, Santiago J. Muñoz, MD, and nephrologist, Karthik M. Ranganna, MD, our entire group is delighted to remain a team and to join the preeminent Tower Health system that is setting national standards for healthcare quality and patient satisfaction. We are deeply committed to excellence in clinical care, improving access to transplant services, and to the expanding academic mission of Tower Health." Dr. Muñoz is Medical Director of Liver Transplant and the Center for Liver Disease, Tower Health Transplant Institute and The Donald Berkowitz Professor of Medicine at Drexel University College of Medicine. Dr. Ranganna is Medical Director of Kidney Transplant, Tower Health Transplant Institute and Associate Professor of Medicine at Drexel University College of Medicine.

Within the Transplant Institute, the Center for Liver Disease will provide comprehensive care and leading-edge therapies to manage and treat a variety of liver diseases."We are pleased to have a new home at Tower Health that will allow us to care for our patients with liver disease without interruption," said Dr. Muñoz. "And, we are excited to work with Tower Health on advancing liver disease services in the region."

Pending approval by UNOS (the Unified Network of Organ Sharing), transplants could begin by the end of 2019. Outpatient services, such as patient pre-surgical evaluation and monitoring and transplant follow-up will begin in September. Communications are underway with patients about the new locations for their care and how to ensure uninterrupted care.

"We are thrilled that Tower Health is able to preserve, and will work to grow, one of the best transplant programs in the country," said Mr. Matthews. "The relocation of this program also represents a major expansion of Tower Health's capabilities in meeting the full spectrum of health needs for the communities we serve."
About Tor renowned team
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Thousands of transplants and we're just beginning.

Monday, December 9, 2019

Patient Abused at State Run Home

By Walter F. Roche Jr.

A 73-year-old dementia patient who became combative, was beaten by a state of Pennsylvania employee assigned to care for the him at a state run facility in Franklin County.
The state employee, who was subsequently arrested, slapped the man after he had struck her. Despite pleas from her co-worker to stop, the employee continued to slap the patient on the chest and arms.
Though she stopped momentarily, the employee then slapped the patient two or three more times.
The incident at the South Mountain Restoration Center was described in detail by a state Health Department inspector in a report issued on July 31.
Court records show that the charges against Melinda V. Rutledge were ultimately dismissed by a Franklin County district judge.
"The resident has a right to be free from abuse and neglect," the state inspection report states, adding that the allegation of abuse was substantiated as a result of the investigation. .
The 73-year-old patient, who had impaired vision in addition to deafness, had a history of traumatic brain injury, the report states.
The report on the incident at the 159-bed facility is not the first to show problems with patient care at the facility. Earlier this year state surveyors found that a female patient was the victim of a male patient who sexually abused her. He was found in the female patient's room with his hand in her briefs.
South Mountain describes itself on its web site as a provider of "compassionate, professional quality care" for patients who have "exhausted other alternatives."
According to the state report the July 21 incident began at 10:45 p.m. when two aides went to the male patient's room to provide care.
"Resident 1 (the male patient) was not co-operating and started to become combative," the report states. The resident then struck the aide and she responded by slapping the patient with an open palm
several times on the arm and chest.
"I told her not to hit him and tried to get her to leave the room," a fellow worker told the state surveyors, adding that the employee then struck the patient two or three more times.
She said she then sought help from another employee, but the aide refused to leave the room. Eventually a supervisor was summoned.
One of the other employees told the surveyors that she told the aide that "it was probably not the best to yell at the patient because he did not have his hearing aides on. That worker said she could hear loud slapping and screaming from another patient's room.
Yet another employee reported that she saw red marks on the patient's side following the incident.
In a response to the report, managers of the facility said that by the next day the red marks had "dissipated" and the patient subsequently underwent a psychiatric evaluation.
They also stated that a subsequent investigation showed no other such events and no other reports of patient abuse were discovered.
According to the management response in-service training was provided for staff and steps were taken to avoid future incidents of "caregiver burnout and compassion fatigue."




























Employee charged after patient struck in Pa.

SOUTH MOUNTAIN, Pa. — An employee of the South Mountain Restoration Center was charged Tuesday after she allegedly struck a resident, Pennsylvania State Police said.

Melinda Victor Rutledge, 38, of Chambersburg, Pa., was served with a summary harassment/physical contact summons by the office of Magisterial District Judge Kelly Rock.

Police went to the center on South Mountain Road on Sunday at 10:45 p.m. and determined that a staff member struck a resident, identified as a 73-year-old man from Wernersville, Pa.

South Mountain Restoration Center is a 159-bed long-term care facility licensed by the Pennsylvania Department of Health, according to the state’s website.

The center is certified by the Centers for Medicare and Medicaid Services, according to the website.







There are 61 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
SOUTH MOUNTAIN RESTORATION CTR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on the findings of an Abbreviated Incident survey completed on July 31, 2019, at South Mountain Restoration Center; the facility was found to be not in compliance with the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.





Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:


Based on clinical record review, facility documentation review and staff interview, it was determined that the facility failed to ensure one of three residents reviewed were free from physical abuse (Resident 1).

Findings include:

Review of Resident 1's on July 29, 2019, at approximately 11:00 AM, revealed diagnoses that included a history of traumatic brain injury (injury to the brain that causes an array of possible cognitive and/or psychomotor deficits), and dementia (irreversible, progressive degenerative disease of the brain that results in decreased contact with reality and difficulty performing activities of daily living).

Review of Resident 1's comprehensive plan of care revealed a care plan wit a focus of, "[Resident 1] is resistive to care at times [related to] Dementia, hearing impairment, and vision impairment," which was initiated on July 8, 2019, and had a goal of, "[Resident 1] will cooperate with care through next review date," which was initiated on July 8 and revised July 12, 2019. Review of the interventions for Resident 1's resistance to care included, "If [Resident 1] resists with [activities of daily living], reassure [Resident 1], leave and return 5-10 minutes later to re-approach."

Review of facility incident investigation report revealed a witness by Nurse Aide (NA) 2, dated July 21, 2019, that stated, "[NA 1] and I went into [Resident 1]'s bedroom to provide care during last rounds at [10:45 PM]. [Resident 1] was not cooperating and started to become combative. The resident struck [NA 1] and after she was struck she slapped the resident with an open palm multiple times on the left arm and chest. I told her not to hit him and tried to get her to leave the room. She then hit the resident 2 or 3 more times on the arm and chest again. I told her to stop and then went and got my coworker who was in the bedroom across the hall. [NA 3] came to the room with me and her and I both tried to get [NA 1] to leave the room, but she wouldn't...After the incident, the supervisor was notified around [11:00 PM] - [11:05 PM]..."

Review of facility witness statement completed by NA 3, dated July 21, 2019, revealed it stated, "Me [NA 3], [NA 1], and [NA 2] were doing last rounds. Start at 10:30 PM as we approached the residents room [NA 2] and [NA 1] went in to and try to put the resident to bed and change him. I [NA 3] went to the next residents room. As I was caring for another resident I could hear [NA 1] yelling at [Resident 1]. When i finish caring for the other resident I left the room and went to [NA 1] and said 'It's probably not the best idea to yell at him," but [NA 1] continued." During a staff interview on July 29, 2019, at approximately 12:20 PM, Nursing Home Administrator revealed that, at the time, NA 1 was heard yelling and it was explained to NA 3 that Resident 1 did not have his hearing aides in at the time. NA 3's statement continued, "I [NA 3] went on to care for other residents and as I was caring for them I could hear loud slapping and screaming coming from [NA 1]. Then [NA 2] came over to the room I was giving care in and asked me to please help him because [NA 1] won't stop yelling and hitting [Resident 1]...As I was trying to calm [Resident 1] down I noticed red hand prints on the chest and left shoulder, so I proceeded to get the nurse [Licensed Practical Nurse 1]."

Review of Licensed Practical Nurse [LPN] 1's witness statement dated July 21, 2019, revealed it stated, "[NA 3] came and notified me that [Resident 1] was having behaviors and needed help. When I walked into [Resident 1's] room I saw a red mark on his left side of his chest."

Review of facility investigation report revealed that the facility investigation of allegation of physical abuse by NA 1 against Resident 1 was found to be substantiated.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(1) Management

28 Pa Code 201.29(j) Resident rights

.



Plan of Correction - To be completed: 08/30/2019

1. The red marks associated dissipated the following day. R1 has been seen by Psychiatry for evaluation with recommended medication timing adjustments to improve acceptance of care. R1 meets with his social worker at least weekly for emotional support and encouragement. There have been no other occurrences or events related to abuse for this resident. Residents care plan for emotional distress related to the incident has been updated to reflect weekly visits from the Social Worker to ensure Psychosocial needs being met and improved interventions for staff approach. NA#1 was immediately removed from duty and remains on suspension pending disciplinary action.

2. Current residents on the unit where NA 1 was assigned will have incident reports for all injuries of unknown origin for the last 30 days reviewed to validate that suspected or reported allegations of abuse have been identified and appropriate follow up has been completed. Residents who are capable of verbally communicating will be interviewed by Social Services to validate that there have been no unknown allegations of abuse. Findings of the reviews will be reported to the Quality Assurance and Performance Improvement Committee.

3. In-service training will be completed for nursing staff to include the components of Abuse regulations and accompanying guidelines for these regulatory components. Resources will be provided to all licensed and non-licensed nursing staff in regards to caregiver burn-out and compassion fatigue. All resident grievances are reviewed by the facility's Executive staff to identify any potential issues related to abuse or rights violations and validate that appropriate actions have been taken.

4. The Quality Assurance Director and/or designee will review and audit all grievances as well as incident reports for injuries of unknown origin weekly for 4 weeks and monthly for 3 months to validate that any identified issues related to abuse have been followed up on accordingly. Audits will be reviewed by the QAPI committee to ensure compliance and quality assurance.

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:


Based on observation, clinical record review, facility document review, and staff interview, it was determined that the facility failed to ensure one of three residents reviewed were free of physical restraints (Resident 2).

Findings include:

Review of facility document, with subject of, "Use of Restraints, Seclusion, and Exclusion in State Mental Hospitals and the [South Mountain] Restoration Center," revealed section VII. Restraint," defined a restraint as, "Any method of restricting a person's freedom of movement, physical activity, or normal access to his/her body."

Review of Resident 2's clinical record on July 29, 2019, at approximately 11:30 AM, revealed diagnoses of anoxic brain injury (injury of the brain caused by lack of oxygen that can cause functional and cognitive deficits) and dementia (irreversible, progressive degenerative disease of the brain that results in decreased reality contact and daily functioning ability).

During general observation of the third floor unit on July 29, 2019, at approximately 10:30 AM, Resident 2 was observed ambulating independently in the hallway. Upon observation of Resident 2 it was revealed that Resident 2 had a one-piece suit on that covered Resident 2 from mid-thigh to the neck, and down to mid biceps. Observations of the one-piece suit revaluated an opening in the back of the one-piece suit.

Review of Resident 2's comprehensive plan of care revealed a care plan with a focus of, "Resident 2 has an [activities of daily living] self-care performance deficit," initiated on February 11, 2015 and last revised on June 23, 2017. Review of the interventions for the aforementioned care plan revealed an intervention of, "[Resident 2] wears one piece jumpsuit open in back due to history of frequently exposing himself," which was initiated on February 11, 2015, and last revised on July 23, 2017.

During a staff interview on July 29, 2019, at approximately 12:30 PM, Nursing Home Administrator revealed that Resident 2 is not able to easily remove the one-piece suit.

Review of Resident 2's physician orders revealed no order for the one-piece suit. Review of Resident 2's clinical record revealed no restraint assessment, and no care plan for the one-piece suit.

During a staff interview on July 29, 2019, at approximately 2:30 PM, Nursing Home Administrator revealed that Resident 2's one-piece suit was considered a safety device. During the interview, Nursing Home Administrator revealed that safety devices were not considered restraints.

28 Pa Code 211.8(c)(d)(e)(f) Use of restraints

28 Pa Code 211.12(d)(5) Nursing services



Plan of Correction - To be completed: 08/30/2019

1. The staff began a trial with traditional clothing for Resident #2 immediately following the survey. Staff are working to identify style of clothing best suited to resident's need given activity level and safety awareness.. Resident #2's Plan of Care has been updated to reflect that he no longer wears one piece suits and utilizes typical clothing. The facility has developed a Procedure for the use of one-piece suit for the purpose of health, safety or dignity of residents or peers and the nursing staff and physicians will be educated on this procedure. If R2 presents with the potential need for one piece suits, the procedure will be followed.

2. There are no other residents in this facility using a one piece suit at this time. If a resident presents with the potential need in the future, the facility procedure will be followed.

3. In-service training will be completed with nursing staff and facility staff physicians regarding One Piece Suit Procedure and in relation to the F604 tag, requirements of trial use when implementing, observations, need for physician's order, and proper Care Planning of use. Training completion will be reported to the Quality Assurance and Performance Improvement Committee.

4. The Quality Assurance Director and/or designee will review and monitor all residents in the facility for use on One Piece Suits for a period of 6 months. This review will include proper implementation of the procedures, proper documentation of the trial and implementation of physician order, and communication of need with the staff. Any new implementations of One Piece Suits will be reported to the Executive Staff via the Executive Staff Morning Report. Monitoring will be reported monthly to the QAPI Committee.
______
Tuesday, April 30, 2019
PA Run Home Failed to Protect Patients


By Walter F. Roche Jr.

A Pennsylvania run nursing home has been cited by one of its own agencies for failing to meet federal health care standards including leaving female residents subject to sexual abuse by a male resident, whose behavior could not be controlled.
In a lengthy report issued by the state Health Department, the South Mountain Restoration Center in rural Franklin County, was also faulted for failing to take steps to prevent vulnerable residents from repeated falls, falls resulting in fractures and other injuries.
The report was based on an inspection conducted earlier this year to determine the facilities compliance with minimum standards for the federally funded Medicare and Medicaid programs. The 159-bed facility is licensed as a nursing home and bills itself as a provider of "compassionate, professional quality care" for patients who have "exhausted other alternatives."
According to the state web site for the center, its patients include former residents of state centers and correctional institutions.
Based on a review of patient records and interviews with patients and employees, surveyors from the state Health Department listed multiple examples of the failure to meet minimum standards in categories ranging from infection control to food handling and maintaining proper individual patient records. The facility was cite for similar deficiencies in the past but failed to implement promised corrective action plans filed in response to those prior citations.
The state Department of Human Services did not respond to a request for comment on the report. The facility did file a corrective action plan in which it promised to make needed corrections.
One male resident, was the focus of several citations in the new report, including touching the breast of one patient and placing his hands in the underwear of another.
The facility "failed to ensure patients were free of non-consensual sexual contact," the report states.
In mid-May the male patient was found in the room of a female patient with his hand in her briefs.
He was asked to leave immediately, according to the report.
Later that same month he was cited again for touching the breast of another female.
The male patient, the report concludes "did not receive adequate interventions to prevent him from inappropriately touching female patients."
In a separate incident with another male resident, a staffer was cited for slapping the patient with a wet facecloth after he was observed with his genitals exposed. The aide had taken the male patient into a woman's room which was in use by a female patient.
The surveyors review of records showed that steps were not taken to prevent additional falls by patients who were considered at risk for falls. And even when falls occurred facility personnel failed to investigate the cause.
In addition in some cases patient records failed to include details of the fall and resulting injuries.
The 2019 report states that South Mountain failed to ensure that effective infection control plans ere in effect. Residents who had tested positive for the flu were observed wandering around without protective masks.
Staffers, according to the report, failed to follow a doctor's orders for a patient on a feeding tube and, in one case, wrongly recorded the amount of nutrient the patient had received.
Still other deficiencies included failure to investigate a patient's charge of abuse and placing an in-dwelling catheter in a patient without a physician's order.
Contact:wfrochejr999@gmail.com



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Tuesday, December 3, 2019

Honesdale Hospital Fails Inspection


By Walter F. Roche Jr.

Multiple deficiencies, including overuse of restraints on a child, were uncovered in a recent state Health Department review of a Wayne County 114-bed hospital.
The Sept. 27 inspection report on the Wayne Memorial Hospital concluded that the facility failed to meet the minimum requirements for participation in the federally funded Medicare and Medicaid programs.
In addition to the misuse of restraints the surveyors, during a three day site visit, found that hospital failed to obtain proper informed consent in nine of 52 patient records reviewed.
On the restraint issue, state surveyors cited the case of a 13-year-old child who was suicidal and aggressive. Though hospital policy limited juvenile restraint use to two hours, the unnamed patient was kept in restraints on Sept. 22 for four hours in the emergency department.
The informed consent records reviewed during the inspection showed a variety of omissions. Nine of 52 records lacked witness signatures or the time the consent was obtained.
The inspectors found that crash carts had not undergone daily inspections 17 times over a two month period.
More than a dozen physicians at the facility frequently failed to complete patient records within 30 days of discharge.
Other deficiencies included failure to maintain an accurate inventory of controlled substances and failure to properly re-credential seven staffers.
The report cites multiple sanitation issues including dirt, dust and dried food debris in food preparation areas and dust and debris in patient rooms "considered clean and ready for patient admission."
Contact: wfrochejr999@gmail.com

Monday, December 2, 2019

Geisinger Facility Failed Medicare Certification


By Walter F. Roche Jr.

Multiple deficiencies were observed when Pennsylvania health surveyors conducted a Medicare/Medicaid re-certification survey of a Columbia County hospital.
The survey findings on the 76-bed Geisinger-Bloomsburg Hospital were detailed in a report dated Oct. 11 and made public last week. The deficiencies range from failure to properly complete pre-operative exams to failure to maintain one-to-one observation on a patient deemed to be a danger to self.
The surveyors observed hospital personnel examining patients prior to surgery without listening to the heart and lungs. In some cases they reported staffers failed to get complete medical histories
A review of supplies in the obstetrics department showed that sexual assault examination kits were outdated by a year.
"The room had no acceptable sexual assault kits available for immediate use," the report states.
In another finding the report said records showed a failure to perform a mandated review of available equipment.
The inspectors found that in at least two cases the hospital failed to inform the area organ procurement agency of patient deaths.
The surveyors also observed an employee in an operating room without proper attire.
Finally the surveyors cited the hospital for failure to follow established procedures for the use of pain medications. Patient pain assessments both before and after the administration of the pain medication were not always performed.
"The facility was not in compliance" with requirements for participation in the Medicare and Medicaid programs, the report states.
Facility officials filed a plan of correction in which they said equipment and other deficiencies would be corrected and employees would be given re-education programs and audits would be performed to ensure compliance.
Hospital officials did not respond to questions about the state report.
Contact: wfrochejr999@gmail.com

Monday, November 25, 2019

Vet Home Errors Caused Actual Harm


By Walter F. Roche Jr.

A Pennsylvania nursing home serving veterans failed to give a patient needed treatment resulting in "actual harm," including hospitalization and surgery to treat necrotic pressure ulcers, according to a state Health Department report.
Cited by state surveyors was the Southeast Veterans Center in Spring City Chester County which was the subject of an Oct. 10 inspection to determine whether the facility met the minimum requirements for participation in the federally funded Medicare and Medicaid programs. The report concluded that the veterans center did not meet those standards.
The facility failed to monitor and assess the patient's pressure sores and failed to provide necessary treatment for those sores, the report states, adding that those failures resulted in actual harm to the unnamed patient.
Administrators of the 238-bed state run nursing home did file a plan of correction in response to the report and promised to examine each current resident for evidence of pressure sores and to institute a re-education program for employees and to set up an audit program to ensure that all patients get the proper pressure sore care.
Officials of the state Department of Military and Veterans Affairs, which runs state veterans homes, did not respond to requests for comment.
The patient, according to the report, suffered from diabetes and multiple sclerosis and required the assistance of two aides to get out of bed. He also had suffered a stroke.
A review of patient records showed the patient needed to be turned and re-positioned and examined at regular intervals, but records verifying those actually occurred were missing. The records indicated he was only re-positioned twice between July 11 and July 15.
"There was no evidence wound treatment was ordered," the report also states.
As his condition worsened the patient was transferred to a hospital for treatment of a wound infection.
He then underwent surgery for a "necrotic infected stage four sacral decubitus.
"The facility failed to provide the services ordered in the plan of care and failed to identify, assess, monitor and provide treatment necessary in preventing skin breakdown," the surveyors concluded.
Contact: wfrochejr999@gmail.com

Monday, November 18, 2019

Eloping Patient Struck By Vehicle


By Walter F. Roche Jr.

A suicidal patient at a Chester County hospital, who was supposed to be on a one-to-one watch, was able to walk out the door without detection only to be hit by a motor vehicle shortly afterwards.
According to a report by Pennsylvania Health Department surveyors the incident occurred on Aug. 27 at the Chester County Hospital. The surveyors cited the hospital for its failure to protect the patient, a minor, and for its handling of several other psychiatric patients in its emergency department.
The report does not give any details of the injuries suffered by the unnamed patient.
Employees of the 248 bed hospital told the state inspection team that the hospital simply did not have the resources "to handle these patients with behavioral issues. We are dependent on the county to place these patients."
The hospital had yet to file an approved plan of correction when the report was first made public last week. Hospital officials did not respond to a request for comment.
On their Oct. 3 visit to the Penn Health facility observed several patients being kept in hallways due to a lack of available beds.
In fact the eloping patient had just been moved from a patient room to make room for another more critical patient. And the day before that the same patient had eloped by the same door.
The staffer who moved the patient to the emergency area told surveyors,"If I had it to do over again I would not have moved her to a hallway bed."
According to a review of hospital records the patient had told staffers that she needed to go to the bathroom, but instead at 11:50 p.m. exited through an ambulance door, the same one she had used the day before.
The patient, who had been in the hospital for a total of 47 hours, had earlier expressed suicidal ideations telling hospital aides that she didn't want to live anymore. At one point she was placed in a four point restraint, the report states. Then she tried to bite off the restraints.
The surveyors observed other patients in the emergency department bedded indefinitely in hallways. Hospital workers were taking patient histories oin open areas.
They also cited the hospital for failing to protect patients' privacy. One patient was observed in open view removing her gown while undergoing an examination.
Another patient was observed in a loud verbal exchange with security guards.
A hospital employee told the surveyors, "We have to acquire privacy screens."
The staffer assigned to constantly monitor another patient was actually sitting across the hallway from the patient's room.
Citing "a systemic nature of non-compliance," the report states, "A hospital must protect and promote each patient's rights."
Contact: wfrochejr999@gmail.com





Tuesday, November 12, 2019

PA Hospital Lacks Staff, Patients


By Walter F. Roche Jr.


A tiny 10 bed western Pennsylvania hospital has been cited for not functioning as a hospital because of its limited staff and hours.
According to a report from the state Health Department the Edgewood Surgical Hospital in Transfer, PA is only open five days a week and locks its doors on those days at 6 p.m. Transfer is located in Mercer County some 70 miles south of Erie.
Inspectors visited the facility in August and September and found there were no inpatients on either day. The survey was conducted to determine if the facility met minimum standards for participation in the federally funded Medicare and Medicaid programs/
"It was determined the facility failed to function as a hospital, as defined by the Social Security Act in that they in that they were not primarily engaged in providing services to inpatients," the report states.
in December 2018, the facility had one inpatient that stayed for a total of 76 hours and 37 minutes.
A review of hospital record showed that the average length of stay for patients was a little over three days. A further review showed where there were no nurses on duty for extended periods.
The surveyors cited a notice displayed at the facility stating that "A doctor is not present 24 hours a day seven days a week."
A review of monthly logs showed that in December of last year the facility had but one inpatient that stayed for a total of 76 hours and 37 minutes.
When questioned about the inpatient census numbers, a staffer acknowledged that in 43 weeks of a 52 week period there were no inpatients and hospital records listed the hospital as "closed" for those 43 weeks.
In a Plan of Correction filed in response to the inspection report, Edgewood officials promised increased staffing and to remain open 24 hours per day seven days a week.
The Edgewood report marks the second time in recent months that a Pennsylvania hospital has been cited for not functioning as a hospital. A Bucks County hospital, Barix Clinic. surrendered its license as a result of the report.
Inspectors found that that the Langhorne clinic had gone 150 days without having a single patient.
The hospital did not respond to requests for comment.


A tiny Pennsylvania hospital specializing in bariatric surgery has closed its doors and surrendered its license to state health officials.
Once part of a nationwide chain, the Bucks County 23 bed facility was part of Barix Clinics. The only remaining facility is located in Ypsilanti, Michigan.
Known as the Forest Health Medical Center, the Pennsylvania facility has been the subject of critical inspection reports by state Health Department surveyors. In one recent report surveyors noted the facility had gone 150 days without a single patient.
The latest report on the Langhorne clinic is the notation that the facility "relinquished" its certificate of licensure.
A closure inspection was completed on June 19.
Several deficiencies had been cited when the facility underwent a Medicare re-certification in 2018. The Barix company signed a settlement agreement with the federal government in 2013 after investigators found that two HIV positive patients had their surgeries canceled when the test results came in.
The Bucks County hospital has posted a notice on its web site blaming the closure on the refusal of insurance companies to provide adequate patient coverage
"Over the past 15 years, insurance reimbursement to small specialty hospitals has declined significantly. After several years of losses we chose to close rather than drastically cut costs and compromise our unwavering commitment to providing the best patient care. We are sorry for any inconvenience this may cause," the notice states.
Following the critical inspection report the hospital did not file a plan of correction acceptable to the state.
"The facility failed to function as a hospital," the report states, noting that the average daily census ranged from 1.2 to 3.3 patients.
The building at 289 Middletown Boulevard in Langhorne has been sold to Capital Health Primary Care.
Contact: wfrochejr999@gmail.com



Monday, November 11, 2019

Wilkes Barre Hospital Cited Again


By Walter F. Roche Jr.

A Wilkes Barre hospital which was cited for multiple deficiencies last summer has been hit again by a highly critical report by surveyors from the Pennsylvania Health Department.
In a report just made public the state surveyors concluded the PAM (Post Acute Medical) Specialty Hospital, did not meet the basic requirements for participation in the federal Medicare program. The latest report cites the hospital for the way it handled a patient's request to have a so-called full code implemented in a medical emergency'
According to the report the patient had requested to be full code at the time of admission, but was not coded on the date of death, Sept. 9 of this year. The patient died at 2:40 a.m., but a Do Not Resuscitate order was not signed by a physician until 7 p.m.of the same day.
The inspectors also cited the facility for improper handling of several other Do Not Resuscitate orders. In some cases the hospital records showed a lack of verification that a physician discussed end-of-life choices with the patients.
The same facility was cited earlier this year by state surveyors for deficient care provided to patients by nursing staff and a lack of adequate nursing staff. The 36-bed unit is located within the Wilkes Barre General Hospital.
"The nursing service must have adequate numbers of licensed registered nurses and other personnel," the earlier report states.
The latest report also faults the hospital for failing to have dietary orders approved by appropriate staff and for improper handling of organ donor forms.
The hospital did file a Plan of Correction in which it promised to have physicians fully fill out the appropriate forms for end-of-life preferences and for an auditing process to ensure compliance. The plan also calls for disciplinary action to be initiated for non-compliance.
Hospital officials did not respond to requests for comment.
Contact: wfrochejr999@gmail.com














Tuesday, July 30, 2019
Wilkes Barre Hospital Understaffed?

By Walter F. Roche Jr.

A specialty hospital in Wilkes Barre "showed a systemic nature of non-compliance with nursing services," according to a report from the Pennsylvania Health Department.
The highly critical report, the result of three recent visits to the PAM (Post Acute Medical) Specialty Hospital, cited multiple deficiencies in the care provided to patients by the nursing staff.
Six patients were not re-positioned every two hours as ordered, five patients missed weight checks and no assistance was provided a patient who needed help in feeding.
The facility "failed to ensure that nursing administration provided oversight of nursing services," the report states.
The 36-bed unit is located within the Wilkes Barre General Hospital.
Still other deficiencies included failure to check glucose levels before insulin injection, failure to bathe four patients, delays in performing dietary assessments, and failure to send a patient's record to the emergency room along with the patient. The patient ended up in intensive care suffering from acute respiratory failure.
Other records, the surveyors reported, were filled out in advance and inaccurately.
"The nursing service must have adequate numbers of licensed registered nurses and other personnel," the report states
Also noted in the report was the fact that the state surveyor slipped on a wet floor which had no signage.
A plan of correction filed by the hospital includes retraining of staffers and audits to ensure compliance with standards.
The report noted that the hospital failed to implement a prior plan of correction filed earlier this year in response to another critical inspection report.
Contact: wfrochejr999@gmail.com
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Monday, October 28, 2019

Hospital RN Shortage Triggers Walkaways


By Walter F. Roche Jr.

Nearly a dozen patients at a rural Pennsylvania hospital apparently gave up and walked away after waiting an extended time to be seen in the emergency room.
A state inspection report on the Conemaugh Miners Medical Center cited the facility for failing to ensure the availability of nursing personnel for initial assessments.
Of the 11 patients who walked away was a psychiatric patient who ran away multiple times and was finally found hiding in nearby woods.
State surveyors also cited the hospital for failing to identify a patient who was at risk for self harm and for failing to initiate a one on one observation for a patient at risk for suicide.
Reviewing hospital records, the surveyors found that some patients were kept waiting for over an hour before they gave up and walked out.
Eleven patients of 30 patient files reviewed showed no initial assessments, according to the report on the 30 bed hospital in Cambria county. The hospital is part of the Conemaugh Health System.
An examination of the hospital's staffing records showed that at multiple times only one registered nurse was on duty in critical care areas including the emergency room.
Interviews with hospital employees showed a continuing and worsening problem with staffing.
"All weekend there was one registered nurse in the emergency room," one employee told state inspectors.
Records showed only one nurse was on duty for five of 42 shifts reviewed.
"We lost seven registered nurses since February. None were replaced," the surveyors were told. "Staff are getting bitter about working by themselves.
Another employee described filling out a form reporting "unsafe staffing."
"There is nothing I can do to make this better at this time," another employee said expressing frustration
The hospital filed a plan of correction in which it described renewed efforts to recruit additional registered nurses and licensed practical nurses.
Hospital officials said it was their goal to have an initial assessment performed on emergency room patients within 10 minutes of arrival.
Conemaugh is one of several Pennsylvania hospitals cited in recent months for staff shortages, particularly in emergency rooms. In fact a sister facility, the Conemaugh Memorial Medical Center, was cited last summer for severe and chronic staff shortages.
"It's only a matter of time until someone really gets hurt or we lose a baby," an employee told state surveyors.
In the most recent case a patient at York Hospital died in the emergency room when staffers assumed the patient had left when he didn't respond when his name was called. Staff shortages were cited as a contributing cause.
Contact: wfrochejr999@gmail.com



Tuesday, October 15, 2019

Geisinger Facility Cited Again


By Walter F. Roche Jr.

When state inspectors visited a Scranton hospital in August they observed staffers assigned to constantly monitor patients in a mental health unit chatting among themselves and talking on their cell phones.
In addition a search of records showed another patient in the unit who was supposed to be under one-to-one monitoring was not immediately assigned a watcher. The patient had spoken about jumping off a bridge and was considered a suicide risk.
"The facility failed to ensure a staff member was performing a patient required one-to-one direct visual examination," the report states.
The recent visit to the Geisinger Community Medical Center was not the first in which state surveyors found violations of minimum state and federal standards. The same 279 bed facility was cited recently for failure to properly investigate an incident in which a patient was burned during surgery.
A Geisinger facility in Wilkes Barre also has been the subject of multiple critical reports.
In the 13-page Aug. 27 report on the Scranton facility, the surveyors also found ceiling vents that could be used in a suicide attempt and a plastic bag that also could accommodate a suicide effort.
The facility failed to ensure care in a safe environment," the report states.
In a plan of correction filed in response to the critical report, Geisinger officials agreed to quickly replace the ceiling vents and remedy other possible suicide risks.
The hospital also initiated a re-education program for workers in the behavioral unit and barred the use of personal cell phones while on duty.
Contact: wfrochejr999@gmail.com

Saturday, October 12, 2019

Patient Dies Awaiting Care in Hospital ER


By Walter F. Roche Jr.

Staffers at a York,PA hospital concluded that an emergency room patient left without treatment when in fact the patient lay dying in their midst.
An investigation by state surveyors on the Aug. 16 incident at the York Hospital showed staffers passed the dying patient at least a dozen times without checking for vitals. Some passed within 1 to 2 feet of the wheelchair where the patient was seated.
The patient was brought by ambulance to the Wellspan facility at 9:59 a.m. and was discovered unresponsive hours later. The death pronouncement came at 1:31 p.m.
The hospital also was cited for failing to report the incident within 24 hours as required by state law.
Despite a hospital policy requiring periodic rounding, the state investigators review of the patient's record "failed to reveal evidence that anyone had completed rounding, while the patient was in the waiting room."
The nurse who was charged with assessing the patients waiting in the ER never even spoke to or even approached the patient, according to the report.
A review of surveillance footage showed the patient showed no movement from 11:09 a.m. to 12:20 p.m.
The patient, identified as MR1, failed to respond to three calls of his or her name.
The surveyors from the state Health Department noted that two other patients, considered in a less critical status, were treated and released in the interim.
"None of the critical protocols were initiated on the patient," the report states.
The patient had been placed in front of a triage room that was not in use at the time, according to the report.
In a response to the report, the hospital said,"The event has been taken extremely seriously at all levels of the organization."
Wellspan officials called the incident a "rare event," but acknowledged the facility failed to properly care for the patient.
A plan of correction filed by the hospital calls for a series of retraining programs and additional staffing in the emergency room.
Contact: wfrochejr999@gmail.com

Friday, October 4, 2019

Pottsville Hospital Cited in Elopement


By Walter F. Roche Jr.

Multiple deficiencies in the handling of patients needing mental health evaluations were uncovered by state surveyors on a recent visit to a Pottsville hospital.
The surveyors declared a state of "immediate jeopardy" at the 129 bed Lehigh Vallley Hospital-Schuylkill in late August due to the failure to promptly institute one-on-one observation for patients deemed at risk to themselves or others.
The facility "failed to ensure the safety of patients," the report states.
The "immediate jeopardy" was lifted when hospital officials came up with an acceptable plan of correction.
In one case cited in the report a patient who had been taken to the hospital by police for a mental health evaluation was left alone in a waiting area and walked away only to be returned to the hospital by police a second time.
The hospital "failed to put patients immediately on one-to-one observation...resulting in elopements on patients who were petitioned to be at risk to themselves or others," the surveyors reported.
Also cited by the state was the failure to perform a suicide risk assessment on one patient being held on involuntary status.
The report cites the hospital's own policy requiring that a staffer be within arm's length of patients being held involuntarily.
One of the patients not placed on immediate observation had a documented history of suicide attempts.
Other items cited by the inspectors was the failure to obtain written orders for the use of restraints and failure to re-assess every 15 minutes patients being held in restraints.
In its plan of correction the hospital promised a re-education program for staffers handling mental health evaluation cases and a series of audits to ensure staff followed the proper procedures.
Another Lehigh Valley Health facility in East Stroudsburg also was hit with an immediate jeopardy declaration recently. That facility was cited for failing to have staff to constantly observe cardiac monitors.

Immediate Jeopardy (IJ) represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death. These situations must be accurately identified by surveyors, thoroughly investigated, and resolved by the entity as quickly as possible. In addition, noncompliance cited at IJ is the most serious deficiency type, and carries the most serious sanctions for providers, suppliers, or laboratories (entities). An immediate jeopardy situation is one that is clearly identifiable due to the severity of its harm or likelihood for serious harm and the immediate need for it to be corrected to avoid further or future seriou
Contact: wfrochejr999@gmail.com

Friday, September 27, 2019

Surgery Patient Burned at Scranton Hospital


By Walter F. Roche Jr.

A Scranton hospital failed to properly investigate a serious incident in which a patient was burned during a routine surgical procedure, according to a state Health Department report.
The patient, who was undergoing an obstetrical procedure at the Geisinger Community Medical Center, was burned on the upper left thigh when an instrument became disconnected and a cord struck the patient's leg.
"The facility failed to complete an investigation regarding a patient sustaining a burn during a surgical procedure," the report states, adding that the failure amounted to a violation of the state Medical Care Availability and Reduction of Error Act.
State surveyors who visited the 279 bed facility in August also reported that the hospital's patient safety committee also failed to investigate a "serious event."
The patient was injured in early April but when the state inspectors asked for a copy of the investigative report "none was provided."
Also cited in the report was the failure of nursing staff to document a description of the patient's injury. The report states that the wound was 1.5 to 2 centimeters in diameter when the patient was examined by a doctor a little over a month after the incident.
The hospital filed a plan of correction in which it agreed to re-educate staff on the types of incidents that must be investigated and the proper method of conducting such an investigation.
A hospital spokesman said s subsequent investigation showed that "user error" and not equipment failure led to the incident. He said the patient was informed of what happened and the plan of correction was implemented.
The report is the third in recent months to cite a Geisinger hospital. The Geisinger Wyoming Medical Center in Wilkes Barre was cited for failing to immediately assign staff to maintain a constant watch on a suicidal patient. In the third incident Geisinger Wyoming was cited for failure to perform a physician ordered test.

Friday, September 20, 2019

Philly VA Faulted in Death


By Walter F. Roche Jr.

Multiple failures at a Veterans Administration facility in West Philadelphia may have contributed to the unexpected death of a drug dependent patient in late 2017, according to a report issued today by the VA's Inspector General.
According to the report the failures continued even after the unnamed veteran in his mid-30s had passed away on his 10th day of treatment.
The report states that the drug dependent veteran was being treated with methadone after testing revealed elevated levels of oxycodone. He had been sent to Unit 7E, a 20 bed acute behavioral mental health unit.
Citing failures to communicate and failure to respond to symptoms of over-sedation, the IG concluded that opportunities for early intervention were squandered.
The staff failed to monitor EKG changes and did not adequately investigate possible adverse drug interaction, the IG found.
On the day of his death, the IG found, two care givers gave conflicting reports in patient records on the amount of methadone actually administered on that critical day.
And when the patient was found unresponsive on the 10th day of treatment, "Unit 7E was not adequately prepared to effectively respond to the patient's cardiac arrest."
Though some corrective changes were implemented after the 2017 death, the IG found the investigation was deficient because two key caregivers were involved in the analysis.
The Root Cause Analysis of the incident failed to comply with Veterans Health Administration requirements because two caregivers were involved in the analysis, thus creating the possibility of bias.

Tuesday, September 17, 2019

Geisinger Wyoming Gets 2nd Citation


By Walter F. Roche Jr.

For the second time in a matter of a month, a Wilkes Barre hospital has been cited by state regulators for failing to comply with minimum standards.
In a report just made public by the state Health Department, surveyors charged that staffers at the Geisinger - Wyoming Medical Center failed to assign a person to constantly monitor a patient who had expressed thoughts of suicide.
"A patient has a right to receive care in a safe setting," the report on the 286 bed hospital states.
The same facility was cited in June for failing to complete a blood test ordered by a physician for a patient who suffered a stroke days after the test was postponed.
According to the latest report state inspectors declared a state of immediate jeopardy on Aug. 2 after they reviewed hospital records on the care provided to the suicidal patient.
The patient had admitted to having suicidal thoughts "related to her medical condition and chronic pain."
Although the patient's condition mandated that a sitter be assigned to provide constant watch there was "no documentation that a sitter was ordered."
At 12:58 p.m. on July 25 a nurse entered the patient's room to find the patient had a call bell wire held very tightly across her neck. Only then was a sitter assigned to keep the patient under constant watch, according to the state report.
A Geisinger spokesman said that when the patient first came to the hospital she was properly screened and judged not at risk for suicide and not in need of a sitter.
"Days later, when the patient’s change in mood constituted reason for concern, a psychiatric consultation was performed, and a 1:1 sitter was recommended. Before the sitter could be assigned, a provider re-entered the patient’s room and found the patient exhibiting behavior that suggested self-harm," the spokesman continued.
From that point on the patient was not left alone, according to the spokesman, who added that the hospital self-reported the incident to the state.
The hospital's two first plans of correction were rejected as inadequate. The third version was accepted and the state of immediate jeopardy was finally lifted at 5:43 p.m. In that third plan the hospital agreed to make the assignment of a sitter automatic with specified diagnoses. If a sitter is not immediately available a nurse must remain with the patient until a sitter arrives. The plan also calls for audits to be performed to ensure staff are following the revised procedures.
The spokesman said the action plan approved by the state allows for easy implementation of suicide precautions and assignment of sitters.
Contact: wfrochejr999@gmail.com

Friday, September 13, 2019

Geisinger Cited for Missed Test


By Walter F. Roche Jr.

When a patient reported to the Geisinger Wyoming Valley Medical Center for the blood test ordered by a doctor, the laboratory personnel turned the patient away, canceling the appointment. Two days later the patient was back at the hospital suffering from a stroke.
The test that wasn't completed, according to a state Health Department report, was "a test used to diagnose bleeding or clotting disorders and to monitor the treatment with blood thinning medications."
The patient's test was cancelled on June 19. The stroke came on June 21.
A review of the hospital records showed the patient arrived at the hospital emergency department "with signs and symptoms of a stroke." The patient had right vocal chord paralysis, tongue dysphagia and severe expressive aphasia.
"The facility failed to ensure a physician ordered laboratory request was completed," the report states.
"The medical test in question was submitted for instrument analysis; however, the lab result was omitted due to an isolated technical issue," a hospital spokesman said, adding that the patient was informed of the incident.
"Our patients come first at Geisinger, and we work daily to do what is best for them," the spokesman added.
The report by state surveyors who visited the 286 bed Wilkes Barre hospital in early August also cited the hospital for failing to perform a root cause analysis of the incident, a routine procedure to prevent a recurrence of medical errors.
According to the report, by the time the investigation was initiated on June 28 the history from the laboratory analyzer had been removed and "it was too late to download the files." And there was no thumb drive back up.
Surveyors interviewed other hospital employees who said the lab employee never asked for additional information needed for the investigation to continue.
The hospital filed a plan of correction with provisions for the special handling of high priority requests. The plan also includes re-education programs for staff and a series of audits to ensure proper procedures are being followed.
Contact: wfrochejr999@gmail.com

Monday, September 9, 2019

Immediate Jeopardy at Pocono Hospital


By Walter F. Roche Jr.

State surveyors officially declared patients at a Pennsylvania hospital were in "immediate jeopardy" two times over a two day period because physician ordered cardiac monitors for critically ill patients were not being monitored.
The details of the July visit to the 237 bed Lehigh Valley-Pocono Hospital are spelled out in a report just made public by the state Department of Health.
The hospital, the report states, "failed to ensure that patients were provided continuous telemetry monitoring for 36 of 36 patients requiring physician ordered monitoring."
In fact a review of patient records at the East Stroudsburg, facility found multiple cases in which monitors recorded critical changes in a patient's heart condition which produced no response from hospital staff.
Federal regulations define immediate jeopardy as a situation in which actions or in-actions by hospital employees "placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death."
Once a declaration is issued, health providers are required to respond immediately.
According to the report the state survey team declared the first immediate jeopardy at 2:06 p.m. on July 15. That was just 41 minutes after they arrived at the hospital. At 2:46 p.m. the survey team rejected the hospital's first plan of correction. A second plan of correction was submitted at 4:06 p.m. but it also was rejected. A third plan of correction was submitted at 5:22 p.m. and it was accepted at 6:30 p.m.
The immediate jeopardy was back in place at 11:25 a.m. the next morning when surveyors once again found that telemetry monitors were not being continuously monitored.
It was finally lifted at 2:20 p.m. on July 16.
The teams' review of records showed one case in early July when a patient experienced 14 beats of ventricular fibrillation recorded on a monitor, but there was no response from staffers. No vital signs were taken and the physician was not informed, according to the report.
Ventricular fibrillation, the report states, is "considered the most serious cardiac rhythm with the potential to cause cardiac arrest."
Another patient experienced atrial fibrillation, but again there was no response by hospital staff
During the review team's time at the hospital they observed that in three of four cases patients experienced changes in heart rhythms but no staffers responded, even when one of the monitors was alarming.
The corrective action plan finally accepted and put in place by the hospital calls for non-nursing personnel being assigned to constantly monitor all monitors but only after they are educated on the proper procedures.
"They (non nurse personnel) may not be in charge of monitoring," the plan states, adding that monitoring will be their only assignment and they are not to perform other duties.
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Friday, September 6, 2019

Patient Got Wrong Blood Type


By Walter F. Roche Jr.

A pregnant 33-year-old patient was transfused with the wrong blood type at a Hazelton hospital when two nurses failed to verify her name and blood type prior to initiating the transfusion.
A recently released report from the Pennsylvania Health Department details the error which occurred in January at the Lehigh Valley Hospital-Hazelton. The seven-page report indicates the error did not cause any harm. The hospital did not immediately respond to a request for comment.
The patient, who was 24 weeks pregnant, was brought to the hospital on Jan. 8 by ambulance minutes after midnight. According to the report she had severe bleeding and was pale and shivering on arrival.
Though she had no active bleeding on arrival she had extensive vaginal bleeding the night before and was experiencing uterine contractions. She was placed on a heart monitor and a blood transfusion was ordered, the report states.
The records showed there were "positive fetal heart tones and positive fetal movement."
The patient's blood type was O Positive, but when a transfusion was ordered she was transfused with B Positive blood.
"There was no documentation that two registered nurses verified the patient name, date of birth and blood type prior to the administration of the blood," the report states.
"There was documentation MR1 (the 33-year-old patient) received one unit of B Positive blood which was intended for another patient in the emergency room," the report continues.
The surveyors reported that the transfusion was "stopped immediately," adding that records showed the error had no deleterious effect on the patient.
She was subsequently transferred to a tertiary care hospital in stable condition.
The hospital filed a plan of correction in which it agreed to conduct re-education sessions with staffers and revised procedures to ensure that a double check was performed prior to any transfusions.
Contact: wfrochejr999@gmail.com

Wednesday, September 4, 2019

2nd UPMC Hospital Cited in Death


By Walter F. Roche Jr.

For the second time in a matter of days a western Pennsylvania hospital has been cited for failing to monitor a cardiac patient who was later found dead and unresponsive.
In a report made public this week state health surveyors found that a patient at UPMC McKeesport who was supposed to be on a cardiac monitor, was found "slumped over and pulseless" on June 1. Records showed the monitor had become disconnected some three hours earlier but no one responded.
"Time of death was 2:10 p.m.," the report states
That was just days after a similar incident at UPMC Presbyterian Shadyside in which a cardiac monitor became disconnected but no action was taken. That patient was also found dead several hours after the monitor went dark.
In the McKeeport case the health department report states that the patient was admitted on May 31 with a complaint of back pain. A physician ordered a cardiac monitor for May 31 and June 1.
Hospital records show the unnamed patient was discovered with no heartbeat at 1:58 p.m. on June 1. Resuscitation efforts failed and death was declared 12 minutes later.
The hospital also was cited for failing to conduct required cardiac rhythm assessments for the patient and three other cardiac patients in the same time period.
The hospital was also cited for failing to notify state health officials of a serious event within 24 hours of its discovery.
The report dated July 22 was the result of two visits to the facility and was described as an "unannounced special monitoring survey."
The hospital filed a plan of correction in response to the inspection in which it promised a re-education program for staffers on the requirements for cardiac monitoring and assessments for cardiac rhythms.
The Mckeesport report parallels the 18-page report issued on the May 25 UPMC Shadyside incident in which a patient was found unresponsive several hours after the cardiac monitor had became disconnected.
Records showed the monitor lead became disconnected at 11:32 a.m. but no action was taken. The patient was discovered pulseless at 3:52 p.m.
In that case the hospital was also cited for failing to notify the victim's family of the adverse event within seven days.
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Thursday, August 29, 2019

UPMC Cited in Patient Death


By Walter F. Roche Jr.

Multiple errors by staffers at a major Pittsburgh hospital led to the death of a cardiac patient, according to a report by the Pennsylvania Health Department.
The 18-page report on UPMC Presbyterian Shadyside just made public this week states that one patient was found dead several hours after a cardiac monitor became disconnected.
The patient, who was suffering from coronary artery disease, was admitted on May 24 at 9:52 a.m.
A cardiac monitor was ordered at 5:23 p.m., but it didn't become active till 7:45 a.m. the next day. A review of records showed the lead became unplugged at 11:32 a.m., but no action was taken despite an alarm going off.
The patient was found at 3:52 p.m. without a pulse.
"No alarm was triggered to alert staff that MR1 (the patient) had an acute event that required an emergent response," the report states.
The facility "failed to ensure there was sufficient nursing supervision to ensure the patient's cardiac status was continuously monitored," according to the report.
In fact a review of records for 11 cardiac patients showed staffers failed to conduct twice daily cardiac assessments.
In the cardiac patient's case, the hospital also was cited for failing to inform the family about what had happened within seven days of the discovery of the reportable event. The family was finally informed on June 27
The surveyors noted that the hospital also failed to notify the family of another deceased patient (MR12) of the adverse event within seven days.
"Review of MR12 revealed a serious event causing a return to the operating room and contributory to the patient's death was identified on April 3. Review of family notification revealed a letter to the family dated June 3," the report states.
The hospital also was cited for the care provided to another patient who ended up in kidney failure
The report states that the patient had normal kidney function when he was admitted, but suffered acute renal failure when staffers failed to monitor test results as ordered by a physician.
Dosing and blood levels, the report states, were consistent with vancomycin poisoning.
The hospital "failed to administer drugs and biologicals according to a physician's order," the state inspectors reported.
The hospital filed a plan of correction including immediate re-education of staff on the requirements for cardiac and test monitoring. Under the plan audits are to be conducted to assure staff compliance.
Contact: wfrochejr999@gmail.com



Tuesday, August 20, 2019

Staffing Levels Critical at Johnstown Hospital


By Walter F. Roche Jr.

"It's only a matter of time until someone really gets hurt or we lose a baby."
That's what one employee of the Conemaugh Memorial Medical Center told a surveyor from the Pennsylvania Health Department during a recent investigation of chronic staff shortages in the obstetrical department.
The employee was only one of more than 10 who told the surveyors that conditions in the department were at the breaking point.
"We're all afraid of retaliation. Many of our patients are at risk," another employee said, adding that some employees were working "80, 90, or 100 hours per week."
The complaints and concerns were included in a recently released report from the state health agency.
"The facility failed to ensure that a sufficient number of nursing personnel were assigned to provide nursing care needs of patients," the report concludes.
The report also cites the facility for failure to complete a series of required forms when staffers were assigned to work beyond their regularly assigned hours.'
The report stops just short of concluding that the hospital was in violation of a 2009 law placing limits on the number of overtime hours direct care staffers can be required to work. Surveyors did conclude that a review of staffing records showed multiple shifts were not staffed according to the hospital's own staffing guidelines.
The hospital did file a plan of correction in which it promised to hire additional registered nurses and to implement monitoring and audit programs to ensure that sufficient staffing was maintained.
The employees interviewed by the state also cited high turnover of staff due to the increased hours.
"Staff is very unhappy," one employee related noting that staffers were often forced to work a full 12 hour shift without even a lunch break.
"This is the worst it's ever been," a veteran staffer stated, citing a "vicious cycle" when frustrated employees quit leaving the remaining staff with even more work.
The surveyors found that between Jan. 1, 2018 and March 22. 2019 there were 77 instances when staffers were required to work beyond scheduled hours.
The report is not the first in which state health officials questioned the adequacy of staff levels. Two recent reports raised the same issue at two Wilkes Barre health facilities.

Monday, August 19, 2019

Contamination In Pittsburgh Area Hospital OR


By Walter F. Roche Jr.
Pennsylvania surveyors have cited a 200-bed hospital for two instances when contamination was found in an operating room forcing delays in scheduled procedures.
The recent report on the Allegheny Valley Hospital also detailed two instances when facility employees failed to get proper informed consent for surgical procedures. According to the report the hospital did not file a plan of correction for multiple deficiencies.
The report, based on a June 20 visit to the Natrona Heights hospital, focused on a May 13 event when a hospital staffer discovered a piece of bone on a tray needed for an upcoming surgery.
"The tray was then contaminated," the report states.
Another patient record showed staffers in the operating room discovered blood in a depth gauge forcing a delay in that surgery.
In two other cases the state inspectors concluded that surgeries were performed without proper prior consent.
In one case a surgeon repaired a hernia while the consent form showed the patient had consented to surgery for the removal of "a groin mass."
"There was no documentation that the surgeon talked to the family," the report states.
In the second case the report states that there was no mention in the consent form of "a debridement of a wound" on the patient's right heel, which is what occurred.
The state inspectors also reported personally observing on June 18 four staffers in operating rooms without their hair properly covered.
Yet another deficiency cited was the lack of proper operative records in four of eight records reviewed.
The report also faulted the hospital for the failure to record fluid loss in four operative records.
An examination of operating room files showed proper and required operative records were missing in four of eight cases.
According to the report the hospital also failed to "perform air exchange testing on all required areas of the facility.
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Monday, August 12, 2019

Rural PA Hospital Cited for Deficiencies


By Walter F. Roche Jr.

A rural Pennsylvania hospital has been cited for multiple deficiencies including failure to properly sanitize reusable medical equipment and properly dispose of outdated narcotic medications.
In a report based on a May 21-24 visit to the Susquehanna facility surveyors from the state Health Department concluded that the 83-bed Barnes-Kasson County Hospital did not meet the requirements for participation in the federally funded Medicare and Medicaid programs.
The report comes at a time when rural hospitals across the country have been forced to cut back services and even shutdown due to decreased funding.
The first item cited in the newly released report was the failure of the hospital to post a notice informing patients and visitors that there is not a doctor on duty 24 hours a day and seven days a week.
The inspectors also found that the facility did not follow proper procedures in sanitizing reusable medical equipment such as an endoscope. Test strips used to test the equipment were not dated to show when the package was opened. In addition the staffers failed to monitor and record temperatures during the sanitation process as required.
Outdated narcotics were observed at the hospital but those drugs had not been listed on a log of drugs scheduled to be disposed through an outside vendor.
In the dietary department hair of employees was not properly restrained and workers did not change gloves after touching their hair.
In the surgical department surveyors found that in three out of three operating rooms anesthesia staffers were not properly supervised.
Still other deficiencies included the failure of the quality improvement department failed to review data on falls, medication errors and problems with intravenous (IV) administration.
According to the report between Jan. 1, 2019 and May 24 there were 10 falls, 12 medication errors and 14 IV infiltrates. Infiltrates occur when medication in the IV leaks into surrounding tissue.
The hospital filed a plan of correction addressing each of the deficiencies including staff retraining and monitoring to ensure staffers are following required procedures at the hospital..
The plan also includes new signage informing patients a doctor is not always present.
Hospital officials did not respond to a request for comment.
Contact: wfrochejr999@gmail.com

Thursday, August 8, 2019

Hospital Rejected State Records Request

By Walter F. Roche Jr.

When state surveyors showed up at a rural Pennsylvania hospital and asked to look at patient safety and related records they were told they couldn't have them because the records were "confidential and protected."
In fact on three successive days in early June the state surveyors got the same response from officials of the Guthrie Towanda Memorial Hospital. On the next try they were given records but with large sections blacked out.
Left unreadable were sections of the minutes covering discussions and conclusions.
The confrontation earned the 35-bed hospital a citation for failing to comply with state licensing requirements.
"The facility was not able to provide this information because the information was considered confidential and protected," the inspection report states.
The records requested were meeting minutes for committees the hospital is required to maintain for patient safety, performance improvement and infection control.
Subsequently the hospital, located in Towanda, filed a plan of correction in which they promised to provide unredacted copies of the requested minutes by July 30.
The hospital was also cited for installing new imaging equipment without first notifying the state.
Contact: wfrochejr999@gmail.com

Thursday, August 1, 2019

PA Hospital Surrenders License


By Walter F. Roche Jr.

A tiny Pennsylvania hospital specializing in bariatric surgery has closed its doors and surrendered its license to state health officials.
Once part of a nationwide chain, the Bucks County 23 bed facility was part of Barix Clinics. The only remaining facility is located in Ypsilanti, Michigan.
Known as the Forest Health Medical Center, the Pennsylvania facility has been the subject of critical inspection reports by state Health Department surveyors. In one recent report surveyors noted the facility had gone 150 days without a single patient.
The latest report on the Langhorne clinic is the notation that the facility "relinquished" its certificate of licensure.
A closure inspection was completed on June 19.
Several deficiencies had been cited when the facility underwent a Medicare re-certification in 2018. The Barix company signed a settlement agreement with the federal government in 2013 after investigators found that two HIV positive patients had their surgeries canceled when the test results came in.
The Bucks County hospital has posted a notice on its web site blaming the closure on the refusal of insurance companies to provide adequate patient coverage
"Over the past 15 years, insurance reimbursement to small specialty hospitals has declined significantly. After several years of losses we chose to close rather than drastically cut costs and compromise our unwavering commitment to providing the best patient care. We are sorry for any inconvenience this may cause," the notice states.
Following the critical inspection report the hospital did not file a plan of correction acceptable to the state.
"The facility failed to function as a hospital," the report states, noting that the average daily census ranged from 1.2 to 3.3 patients.
The building at 289 Middletown Boulevard in Langhorne has been sold to Capital Health Primary Care.
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Tuesday, July 30, 2019

Wilkes Barre Hospital Understaffed?


By Walter F. Roche Jr.

A specialty hospital in Wilkes Barre "showed a systemic nature of non-compliance with nursing services," according to a report from the Pennsylvania Health Department.
The highly critical report, the result of three recent visits to the PAM (Post Acute Medical) Specialty Hospital, cited multiple deficiencies in the care provided to patients by the nursing staff.
Six patients were not re-positioned every two hours as ordered, five patients missed weight checks and no assistance was provided a patient who needed help in feeding.
The facility "failed to ensure that nursing administration provided oversight of nursing services," the report states.
The 36-bed unit is located within the Wilkes Barre General Hospital.
Still other deficiencies included failure to check glucose levels before insulin injection, failure to bathe four patients, delays in performing dietary assessments, and failure to send a patient's record to the emergency room along with the patient. The patient ended up in intensive care suffering from acute respiratory failure.
Other records, the surveyors reported, were filled out in advance and inaccurately.
"The nursing service must have adequate numbers of licensed registered nurses and other personnel," the report states
Also noted in the report was the fact that the state surveyor slipped on a wet floor which had no signage.
A plan of correction filed by the hospital includes retraining of staffers and audits to ensure compliance with standards.
The report noted that the hospital failed to implement a prior plan of correction filed earlier this year in response to another critical inspection report.
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