Lancaster Behavioral Cited in Suicide Attempt

By Walter F. Roche Jr.

A patient at a Pennsylvania behavioral hospital who was supposed to be on constant one-on-one watch was able to strangulate himself when a worker allowed him to pull a screen across the entrance to a bathroom.
According to a recently released report from the state Health Department, the incident occurred on March 31 at the 126-bed Lancaster Behavioral Health Hospital.
The facility "failed to consistently ensure that all patients received care in a safe setting," the report states.
The patient, who had been admitted on March 23, had been to the facility previously due to continued attempts to harm himself and others.
The patient was supposed to remain under constant observation with a caregiver no farther than an arms-length away.
According to the report the patient "indicated to the caregiver the need to go to the bathroom" and the caregiver allowed the patient to pull a curtain across the bathroom doorway for "privacy."
The caregiver became concerned, however, when there was no noise or sound of movement from the bathroom. When the curtain was pulled back the patient was found on the floor not breathing and with two socks around the neck.
A code was called, the report states.
A hospital spokesman said the patient survived and was taken to a local emergency room. The state report, however, does not indicate whether resuscitation efforts were successful.
"The caregiver should have maintained direct observation," the report states, adding that he should not have been allowed to pull back the curtain.
"The caregiver should have maintained constant observation and not permitted the curtain to be pulled back thus blocking the ability to continuously visualize the patient," according to the state survey report.
In addition to failing to properly monitor the patient the facility was cited for failure to have a working walkkie talkie system. The caregiver involved in the March 30 incident did not have a walkie talkie apparently because the units were unreliable.
The hospital, which is a partnership between Universal Health Services, Lancaster General Health and Penn Health, filed a plan of correction in which they agreed to conduct education and retraining sessions for staffers. The facility also promised to purchase a new communication system.
The report dated April 10 was the second in less than a month in which the hospital was cited for deficiencies.
In a March report surveyors concluded the facility failed to properly investigate an incident in which a patient was given the wrong version of an anti-psychotic drug. The hospital opened in 2018.
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Cardiac Monitor Turned Off at PA Hospital.

By Walter F. Roche Jr.

Nursing staff at a Pennsylvania hospital falsified records in an incident in which a patient who was supposed to be constantly monitored was found unresponsive several hours after the monitor was turned off.
The March incident at the Geisinger-Wyoming Valley Medical Center was only one of multiple deficiencies found by state Health Department surveyors at the 286 bed Wilkes Barre hospital in March. Also cited was the failure of the hospital to immediately notify the family of an accident victim who had been admitted to the hospital.
The inspectors declared a state of immediate jeopardy when they began the inspection at 2:30 p.m. on March 12. That forced hospital officials to immediately prepare a plan of correction. However, the first two plans were rejected as inadequate. An acceptable plan was submitted on the third try and the state of immediate jeopardy was lifted at 6:52 p.m.
The report faults the hospital and its administrators for failing to ensure a cardiac monitor was not turned off at a patient's bedside on March 5. The patient, identified as MR1, had been admitted the day before after suffering a fall at home.
In fact, the surveyors concluded, the hospital failed to properly monitor telemetry units for a total of 111 patients.
The review of hospital records showed the monitor on MR1 who had multiple cardiac problems went offline at 8:05 p.m. The patient was found unresponsive with no heart beat at 11 p.m. when a nurse went into the patient's room to administer medication.
Further records reviews showed the patient's medical record showed the patient had been checked at 8, 9 and 10 p.m.
"Employee 7 confirmed MR1's medical record was not accurate and contained misinformation," the report states.
"Records show the required rounding on MR1 was not performed," the report states.
In the case of the accident victim, state surveyors reported that the patient, who had been hit by a car, was brought to the hospital on Feb. 8. The identity of the unresponsive victim was confirmed later that day from a prescription bottle, but the patient's family was not notified until Feb. 11.
Other deficiencies cited included placing a combative patient in wrist and ankle restraints without first considering less restrictive alternatives.
Reviews of other records showed a medical staffer was re-appointed without performing required background checks.
The hospital filed a plan of correction which includes staff retraining and the implementation of a monitoring program to ensure compliance with state and federal standards. The hospital did not respond to a request for comment.
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Care Wanting at PA Vets Home

By Walter F. Roche Jr.

A Pennsylvania nursing home for veterans has been cited by state health officials for failing to take proper action in response to multiple residents suffering from severe rashes and scabies.
According to a recently released report from the state Health Department staffers at the 257-bed Hollidaysburg Veterans Center in Blair County failed to make proper assessments or monitor five of eight patients with widespread rashes and scabies, a contagious skin disease caused by mites.
One resident, according to the report, had a rash over the entire back and upper arms.
In addition the state surveyors reported that an employee who also came down with scabies was allowed to return to work before getting a release from a physician. The unnamed employee, a nurse's aide, had been diagnosed with scabies in late February and returned to work March 1 without the required physician's clearance.
On March 5, the same aide called out when the scabies apparently resurfaced.
She returned five days later, this time with a doctor's okay.
The state health inspectors concluded from a review of Hollidaysburg records that staffers failed on multiple occasions to complete required daily monitoring of the five patients suffering from rashes or scabies.
Facility officials filed a plan of correction with the Health Department in which they agreed to retrain staffers on the assessment and monitoring requirements. The agency response included the results of an assessment of the patients with the skin and rash problems and the subsequent treatment ordered by a physician.
Some of the residents, the plan of correction states, were subsequently diagnosed with allergic dermatitis rather than scabies.
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Appeals Court Upholds VA Firing

By Walter F. Roche Jr.
A federal appeals court today affirmed the termination of a key Veterans Administration official implicated in the widespread delay Phoenix area veterans faced in getting needed medical appointments.
In a 30-page decision the Court of Appeals for the Federal Circuit upheld the firing of Lance Robinson who was associate director of the Phoenix Veterans Administration Health Care System.
The three judge panel concluded the Merit Systems Protection Board did not abuse its discretion in upholding Robinson's 2016 termination.
Robinson's duties included oversight of the unit scheduling veterans' medical appointments
His termination came after the Phoenix VA came under congressional scrutiny following the disclosure that 40 veterans had died while on secret waiting lists.
"During his tenure Mr. Robinson was aware that scheduling systems were a problem, including that it often took more than 30 days for patients to get new medical appointments," the ruling states.
As the decision states, Robinson was placed on administrative leave in 2014 and returned to duty in 2016.
He was terminated June 7, 2016 on charges that he negligently performed his duties and failed to provide accurate information to his supervisors.
"In short the answer is yes," the court concluded as to the question of whether Robinson was negligent.
Citing his "hands-off" approach to management, the ruling states, "Substantial evidence support a finding that Mr. Robinson knew or should have known of his subordinates failure" to meet scheduling requirements.
"Substantial evidence shows Mr. Robinson had actual knowledge of the Phoenix VA's scheduling problem," the ruling states.
The panel also dismissed Robinson's claim that the punishment, his termination, was too severe.

PA Hospital Turned Stroke Victim Away

By Walter F. Roche Jr.

In an apparent violation of federal law, a Pennsylvania hospital turned away a stroke patient forcing emergency responders to travel more than 40 miles to another health facility.
According to a recently released report from the state Health Department the ambulance carrying the patient had already pulled into the hospital's emergency room unloading area when the crew was diverted to another facility.
The incident occurred on March 19 at UPMC-Bedford. The report states that after being turned away from the Bedford facility, the patient was taken to UPMC-Altoona, some 43 miles away.
Citing a federal law, the report states that when a health facility has an emergency service "it shall provide prompt examination or treatment."
"If an individual comes to any portion of a medical facility" a medical screening and examination must be performed," the report states, citing the federal Emergency Medical Treatment and Active Labor Act.
UPMC-Bedford officials did not respond to questions concerning the incident and the inspection report. They did file a plan of correction in which they promised to re-train staffers and perform audits to ensure staffers followed proper procedures.
State surveyors, acting on a complaint, examined records at the Bedford hospital and the Bedford Area Ambulance Service. The 47-bed facility boasts on its website that it provides "Certified Acute Stroke Care" 24/7.
The records showed the ambulance service contacted the hospital around 7:15 p.m. notifying officials there that they were en-route.
Hospital officials responded by asking if the patient could be diverted to Altoona.
"You are the closest hospital and I don't feel comfortable going to Altoona," the EMT responded, according to the report.
Moments later the ambulance crew told the UPMC employee that they were already at the hospital and were pulling in to the parking lot.
"We are here at the hospital now," the EMT stated.
"I still think you should go there now," the hospital official said, noting that the Altoona facility had an interventional radiology laboratory.
In a subsequent interview the employee told state surveyors that he knew about the federal law but he didn't realize the ambulance was already at the hospital.
"I would never turn anyone away or put a patient at risk. I thought I made the best decision," the hospital official added.
"I didn't believe they were outside. If I thought that they were there, I would have treated the patient. I realize it was a mistake," the employee told state inspectors.
The state report also faulted the hospital for failing to even enter the patient's name into its records.
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Jury Convicts Two From NECC

By Walter F. Roche Jr.

BOSTON- Acting within less than two hours, a federal jury today found two pharmacists guilty of violations of federal drug laws when they worked for a drug compounding firm blamed for a deadly 2012 fungal meningitis outbreak.
Convicted on a total of six felony counts were Kathy Chin and Michelle Thomas. Both worked for the now defunct New England Compounding Center. The two were charged with violations of the Food Drug and Cosmetic Act when they issued drugs based on prescriptions for patients with clearly fake names.
U.S. District Judge Richard G. Stearns set August dates for their sentencing.
They were charged with placing mis-branded drugs in interstate commerce. Chin was convicted on four counts of misbranding with intent to defraud or deceive. While Thomas was convicted on two counts of the same charges.
The two were among 14 indicted following a two year probe of the fungal meningitis outbreak which took the lives of some 100 patients nationwide including at least 16 from Tennessee.
Only one of the 14 has been acquitted of all charges while others have been convicted or entered guilty pleas. They including Chin's husband Glenn, who is serving an eight year prison sentence.
The charges against Kathy Chin and Robinson were not for drugs that caused the outbreak but for other drugs compounded at NECC's Framingham, Mass. facilities.
Specifically they were charged in the compounding of drugs shipped to health providers in Nebraska and Georgia.
During final arguments before the jury began deliberations, Assistant U.S. Attorney Amanda Strachan said the two were part of a massive fraud.
"It was fraud through and through," Strachan said. "It was NECC's business model."
She said the two distributed drugs with prescriptions made out to fake patients. Evidence presented to the jury included prescriptions with patient names including L.L. Bean and Filet O Fish.
Joan Griffin, Chin's lawyer, called the verdict "very disturbing" and said an appeal will be filed.
Both she and Michael Bourbeau, Thomas' lawyer, had argued that NECC's part owner and president Barry J. Cadden was the responsible party. Cadden is serving a nine year sentence in federal prison and he and Chin are facing multiple second degree murder charges in Michigan. They were convicted on racketeering and mail fraud charges in separate federal trials.
Five others affiliated with NECC or its sales arm were recentl convicted of related charges and are awaiting sentencing.
The jury verdict was delivered by only 11 of the original 12. One juror was dismissed after he disclosed that he had prior dealings with one of the prosecution witnesses, a criminal investigator for the U.S. Food and Drug Administration
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WWII Vet Who Fought For Benefits Passes

By Walter F. Roche Jr.

For Millard Sells the longest battle was not in Iwo Jima, where he served in World War II, but back home in the United States where he fought for more than two decades to get the benefits he was entitled to as a U.S. Marine combat veteran.
Sells, 93, was laid to rest today in Pickett County even as the battle for a few last benefits continues toward a final chapter.
His attorney, John Cameron, said some additional benefits, would likely go to his widow Christine.
It was five years ago, after a 19-year struggle, that Veteran s Administration officials, with prodding from a federal judge, finally granted Sells a 100 per cent disability based on his service injuries.
Alice, Sells daughter,said her father died at the VA Hospital in Nashville on Sunday where he was being treated for pneumonia. She said he had struggled in his final weeks but was unable to overcome the pneumonia.
"Dad has had previous emergency admissions due to aspirations/pneumonia but this was much worse," she said.
"He died very peacefully and was told everyday how much he was loved and what a good husband and father he is. He was still a proud Marine," she added.
At memorial services in Byrdstown today his widow was presented with a flag by a U.S. Marine representative.
Sells said her father had grown tired of the long battle for benefits, but with the aid of Cameron, an Alabama attorney specializing in veterans issues, the battle continued.
Court records show Sells and Cameron were bounced back and forth between an agency board and a federal courtroom to get answers from the VA. Those battles began with the VA's regional office in Nashville.
At one point a federal judge had to order the VA to at least respond to Sells' repeated requests for basic data on his case.
"The petitioner further asserts that he has made at least eight written requests," Judge Mary Schoelen wrote in a two-page order.
As for the source of his physical injuries and post traumatic stress, Sells recalled in a 2014 interview his service in the Pacific
Once the 5th Marines Division had landed on Iwo Jima in February 1945, Sells said that his commander ordered him and four other Marines to act as scouts.
"There was extreme fire, and we got caught behind enemy lines. Three didn't come back," Sells said. He suffered additional service injuries after the battle before returning to the mainland.
As for the battle for benefits Sells said the VA kept claiming he had missed a deadline or hadn't filed a claim at all. He first sought benefits in 1995 when he had to give up a job as a school bus driver due to persistent pain.
"They'd claim they never got it," Sells said, adding that he always sent his appeals by registered mail. Records in the case show VA officials also repeatedly questioned the extent of Sells' disabilities.
Cameron said the belated award of a 100 per cent disability, which came just before Sells 88th birthday, still didn't provide full benefits back to the time of his original 1995 claim. He said his widow also could receive additional benefits based on the cause of his death.