Tuesday, June 25, 2019

Probe of Vets Home Death Continues

By Walter F. Roche Jr.

A criminal probe into the beating death of a 95-year-old man who was a patient at a state-run veterans nursing home remains open, according to Lackawanna County District Attorney Mark Powell.
The victim, Leonard Fiume, died in late April only days after his bloodied body was found in a patient room at the 196-bed Gino J. Merli Veterans Center in Scranton, PA.
In a report made public late last week, inspectors from the state health Department blamed a sister agency, the Department of Military and Veterans Affairs, for failing to protect Leonard Fiume.
"The facility failed to prevent the physical abuse of one resident which resulted in serious bodily and physical injury and subsequent death of one resident," the report states.
Asked for comment, a spokeswoman for the agency that runs the state veterans homes, said the agency was continuing to work with the Scranton Police Department.
"We are working with the Scranton Police Department and are unable to comment further as this is part of an ongoing investigation, Joan Nissley wrote in an email response to questions.
The Health Department report states that Scranton Police have determined that the death was a homicide.
Fiume was found in room 220 at the Gino Merli Veterans Center along with a 78-year old Alzheimer's patient. Neither of them was assigned to the room, which was apparently empty.entered the second floor room separately a few minutes apart on April 22. They were together in the room for about 11 minutes.
They were discovered when a nurse passing the room heard a wheelchair alarm go off, which meant a patient was no longer sitting in the wheelchair. She then discovered Fiume lying bloodied on the floor and the 78-year-old close by. The younger patient charged that Fiume had come up from behind and started attacking him.
"He (Fiume) just started hitting me. He came from behind. I tried to protect myself," the 78-year-old told the health inspectors.
According to the report Fiume and the 78-year-old had confrontations in the past and the 78-year old had struck Fiume's wife, also a Merli resident, on the leg.
Fiume died in a local hospice four days after the confrontation.
Contact: wfrochejr999@gmail.com

Saturday, June 22, 2019

State Blamed in Beating Death of Patient

By Walter F. Roche Jr.

"There was blood everywhere."
That's how one employee of a Pennsylvania veterans home described the scene when a patient was found recently with what turned out to be fatal injuries.
The 95-year-old victim had been beaten by a fellow patient who also was found in the second floor room at the Gino Merli Veterans Center in Scranton on April 22.
The detailed minute by minute description of the deadly confrontation was spelled out in a 10-page report just made public by the state Health Department.
The report faults the home itself for failing to protect the patient.
"The facility failed to prevent the physical abuse of one resident which resulted in serious bodily and physical injury and subsequent death of one resident," the report states.
Officials of the state Department of Military and Veterans Affairs, which runs the home, did not immediately respond to a request for comment.
From extensive interviews and reviews of surveillance tapes,and hospital records, the state inspectors reconstructed the bloody April 22 scene where 95-year-old Leonard Fiume was fatally beaten.
The report also details the fact that the deadly confrontation was not the first time the two had clashed.
In fact the 78-year-old Alzheimer's patient who inflicted the injuries had previously hit the victims's wife, also a resident of the home.
Fiume and the 78-year-old had a direct confrontation a little less than a month earlier when the two, both confined to wheelchairs, began kicking each other and the 78-year-old punched the 95-year-old in the face.
Just four days before the final clash the 78-year-old became very agitated with staff and shook a fist at one of them.
Video of the April 22 event showed that the 78-year-old and Fiume entered Room 220 separately about eight minutes apart. Neither of them was assigned to the room. They were in the room together for 11 minutes "during which time Resident 2 (the 78-year-old) had physically assaulted and seriously injured Resident 1 (the 95-year-old) resulting in Resident 1's death."
At 1:14 p.m. a nurse passing in the hallway heard a wheelchair alarm go off. The alarm indicated a patient was no longer sitting in the wheelchair.
The nurse tried to enter the room but the door was blocked. She then went to the the next room and reached 220 through a shared bathroom.
She found Fiume lying on the floor with his wheelchair blocking the door. The 78-year-old was in the room and told the nurse, "He (Fiume) just started hitting me. He came from behind. I tried to protect myself."
Blood spatter was observed on the walls, door and doorway, the report states. There was blood spatter on the pillow on the 95-year-olds wheelchair, according to the report.
The 95-year-old had a laceration on the right side of his temple. Subsequent tests showed he had a subdural hematoma on the left side of his brain. The report noted that the 95-year old was taking anti-coagulant medications making him more susceptible to bleeding.
The 78-year-old had blood on his hands and complained of pain. Both were sent to a local emergency room, but the 78-year-old was released the same day.
The report states that Fiume's condition worsened over night and any surgery was ruled out. He was transferred to hospice care on April 26 and died the same day.
According to the report after the 78-year-old returned to the home he was placed under constant watch.
The report states that Fiume's cause of death was "blunt force head trauma and local police determined it was a homicide"
The victim's son declined to press charges, the report concludes.

Wednesday, June 19, 2019

Facility Failed to Investigate, Report Patient Death

By Walter F. Roche Jr.

"It was something that just happen."
That's what an employee of the Bryn Mawr Rehabilitation Hospital told a state surveyor when questioned recently about the July 16, 2017 death of a patient.
Following the inspection the 148-bed hospital, part of Main Line Health, was cited for failure to investigate and report the death of a patient who was found unresponsive with her tracheotomy tube disconnected.
According to the report the patient who had been admitted to the Malvern facility on May 3, 2017, was discovered two weeks after admittance with a dislodged tracheotomy tube. The patient was unresponsive without a pulse and resuscitation efforts were unsuccessful.
As the May 8 report states, the state Medical Care Availability Act required that the hospital report the event within 24 hours of its discovery. Reports must be filed both with the state Health Department and the state Patient Safety Authority.
Events that must be reported, the state surveyors noted, are unplanned occurrences not consistent with the routine care of the patient.
When asked why the hospital did not report the death or do its own investigation of the incident, a hospital employee said, "It was not perceived as a reportable event. It was something that just happen during the course of the patient's hospitalization."
The hospital also was cited for failing to comply with hand hygiene standards even though its own records showed compliance in some areas of the hospital only achieved a 40 per cent compliance rate.
Neither the July 17 death nor the hand hygiene issues were reported to the hospital's quality control committee.
Still another citation was issued after inspectors discovered the hospital had upgraded its nurse call system without the state being notified 60 days in advance. The inspectors also found fault with credentialing actions at the facility.
State Health Department records state that the facility has yet to file an acceptable plan of correction, but a hospital spokeswoman issued a statement expressing confidence that the latest submission will be accepted.
"Bryn Mawr Rehabilitation Hospital’s first priority is to ensure the safety of all those who rely on us for care. We have submitted a plan of correction and are confident that our plan addresses and corrects the issues identified, and demonstrates Bryn Mawr Rehabilitation Hospital’s and Main Line Health’s ongoing commitment to a culture of safety and highly reliable, quality care," said Mary Kate Coghlan.
The facility did not respond to specific questions about the patient cited in the report.
Contact: wfrochejr999@gmail.com

Thursday, June 13, 2019

Pittsburgh Hospital Tasered Patient

By Walter F. Roche Jr.

State inspectors declared a state of immediate jeopardy at a Pittsburgh hospital recently after learning that a 78-year-old patient, who had threatened nurses with a pair of scissors, was tasered in violation of federal standards and its own policies.
The citation against the 315 bed Forbes Hospital marked the second time in a matter of weeks that Pennsylvania health surveyors cited a licensed facility for improper use of tasers. The other facility cited recently was UPMC Hanover.
According to the report on the Forbes incident, the patient identified as MR1 was tasered after becoming verbally and physically aggressive.
On March 13, the report states, the patient left his room, grabbed a pair of metal scissors from a nurses station and cut his IV line and cardiac monitor. He entered another patient's room. The other patient, the report states, was yelling and screaming.
"When nurses approached he threatened them with scissors and made a stabbing motion," the report continues.
Stating that the patient became "more and more agitated and aggressive," the state surveyors said the patient then made ominous threats about "not going down alone" and continued to lunge at staff.
"Security was forced to subdue MR1 by using a taser," the surveyors reported.
The patient then dropped the scissors and was assisted to his room. He was placed in bed, restraints were applied and he was given a dose of Haldol.
As they did in the UPMC case, the surveyors noted that a taser should not be used to apply restraints.
"The use of weapons in the application of restraints is not considered a safe and appropriate health care intervention," the report states. "Although the taser was to be used as a law enforcement tool, the patient was never placed in law enforcement custody."
The hospital filed a plan of correction in which it said the use of tasers would only be considered as a law enforcement action and staff would be retrained in the proper use.
In addition the hospital promised that a taser would never be used on a person known to be a patient.
The state of immediate jeopardy was lifted about four hours after it was declared.
The state report also cited Forbes for improperly using restraints in three of five patient records reviewed. A third citation was issued for failing to document that patients were advised of their rights.
Contact: wfrochejr999@gmail.com

Thursday, June 6, 2019

Suicide Attempt at Lewistown Hospital

By Walter F. Roche Jr.

A Lewistown hospital failed to assign a one-on-one monitor to a patient with a recent history of suicide attempts enabling the patient to attempt suicide for a third time.
A recently released report on a special monitoring investigation on the 123-bed Geisinger Lewistown Hospital showed the hospital failed to follow its own set procedures when the suicidal patient showed up in the emergency room on March 15.
The patient, according to the report made public recently, had overdosed on Tizanidine and gabapentin. Sixty-two Gabapentin pills were missing along with 18 Tizanidine, investigators found. Left unmonitored the patient was discovered with a call bell cord wrapped around his neck.
The patient was pulling the cord tightly and wouldn't let go, state surveyors learned after a review of hospital records. The cord had to be forcefully removed.
The hospital has yet to file a required plan of correction and officials did not respond to a request for comment.
The patient was described as highly impulsive, had suicidal thoughts and expressed a desire to be dead with a specific plan, the report states.
Despite the fact that the patient had a score on an assessment test more than double the amount triggering the requirement for one-on-one monitoring, no monitor was assigned until after the suicide attempt was detected.
The report also faults the hospital for not removing from the patient's area any objects that could be used for self harm.
State inspectors examined records of other psychiatric patients at the facility and found that the facility in another recent case failed to even assign a score on the assessment test.
Contact: wfrochejr999@gmail.com

Tuesday, June 4, 2019

Hospital Tasered Unruly Patient

By Walter F. Roche Jr.

A Pennsylvania hospital has been cited for failing to follow its own procedures when it tasered a patient who had become physically and verbally agressive.
In a report recently made public by the state Health Department, UPMC Hanover was charged with placing the patient and others at the facility in danger of "serious injury or harm."
According to the report, the hospital has yet to come up with an acceptable plan of correction.
Kelly Mccall, a spokeswoman for the hospital, however, said a plan of correction has been filed which included removing the tasers from the facility and a series of education and retraining sessions for staff along with policy revisions.
Mccall said privacy rules bar the hospital from discussing specific cases, but said the hospital self reported the incident to the state Health Department.
"Patient and staff safety is always our top priority, and we are committed to ensuring the safest possible environment for patient care," she said.
State surveyors reported that the incident took place on March 26 when the patient, who was on a suicide watch, demanded he be allowed to wear his boxer shorts. When he was told he had to remain in hospital scrubs, the patient became verbally and physically abusive and kicked a nurse.
He subsequently banged his head on a counter and said, "Why don't you just kill me.?"
A "Code Green" was called, the report states.
"The patient was going to hurt someone. That is why a code was called," hospital staffers told the state surveyors.
The patient was described as muscular and weighed 200 pounds.
Police were called but they declined to take the patient into custody, hospital records showed.
A hospital security employee then tasered the patient in the abdomen and while he was on the floor other employees placed him in restraints and treated him with drugs including Ativan and Zyprexa, an anti-psychotic.
According to hospital records, the taser had been purchased in 2015 but was only supposed to be used when a patient was being placed in police custody,not as a means of placing a patient in restraints. In addition it was not to be used until all other possible interventions had failed.
"All the patients have the right to be free from physical or mental abuse," the report states, adding that the multiple failures in the handling of the incident placed the patient and others at risk.
After the patient was restrained he was medicated and calmed down in about 20 minutes, the surveyors reported.
He was later transferred to another facility, the inspectors reported.
A review of hospital records by the state inspectors showed restraints were used improperly on three of six patient records reviewed.
Contact: wfrochejr999@gmail.com