Temple Cited in Patient Suicide

By Walter F. Roche Jr.

Citing a discrepancy between hospital records and video surveilance tapes, state Health Department investigators have concluded that Temple University Hospital workers failed to properly monitor a suicidal patient allowing him to hang himself.
A report on the Sept. 7 suicide at the hospital's Episcopal Campus concludes that while hospital employees were supposed to check on the patient face-to-face every 15 minutes, video tapes showed no one went into the patient's room a single time during a critical more than one hour period.
Nonetheless hospital records stated that the 15 minute checks were dutifully performed.
"Documentation in the medical record showed that 15 minute checks were completed and documented by the mental health technician," the report states.
"The video tape review showed there was a long period of one hour and eight minutes when Patient One was not visualized by a staff member which was in contradiction to the required 15 minute visual checks to be conducted by the staff per hospital policy," according to the report.
"The facility failed to ensure patient monitoring was performed as required," the report states, adding that a registered nurse was ultimately responsible but failed to ensure that the 15 minute checks were actually being performed.
The investigation showed that the unnamed patient tore up a sheet and attached it to a shower curtain rod and then hung himself.
The hospital also was cited for failing to remove ligature risks (the curtain rods) from an area where suicidal patients were being treated. The report does state that the curtain rods in the unit were immediately removed while surveyors were conducting their review.
Further review of video tapes showed there were 17 missed 15 minute checks in the behavioral unit in a two day period including the day of the suicide.
"This placed 21 patients at risk for harm, serious injury or death," the surveyors concluded.
The hospital failed to file an acceptable plan of correction and did not repond to requests for comment.
Contact: wfrochejr999@gmail.com

Multiple Covid-19 Violations at PA Hospital

By Walter F. Roche Jr.

State surveyors say multiple violations of Covid-19 care requirements were observed at a 149-bed behavioral hospital, including an employee, who had tested positive for the virus interacting with a patient without properly wearing a face mask.
The details of the September survey at the First Hospital of the Wyoming Valley were included in a report made public late last week. The violations of state and federal rules on care for Covid-19 cases were observed both in person and by viewing surveillance videos at the Kingston facility.
The surveyors visited the hospital on Sept. 4 and again from Sept. 8 to Sept. 10.
The violations ranged from failing to properly screen patients prior to admission to failure to provide oversight of nursing staff to ensure they were properly using Personal Protective Equipment.
Surveyors personally observed an employee using a cell phone, a prohibited practice, in a patient care area.
The facility policy required leaving personal cell phones in a first floor locker room, according to the Sept. 10 report.
The hospital is part of Commonwealth Health, which boasts of its system-wide measures to keep patients and visitors safe during the ongoing pandemic.
A hospital spokeswoman, Annmarie Poslock, said the facility "implemented a plan of correction accepted by the Pennsylvania Department of Health following the September inspection." She said directors and providers have been retrained on infection control protocols established by the Centers for Disease Control and Prevention including the appropriate use of personal protective equipment.
She said the hospital does not currently have any Covid-19 cases. The hospital also was cited for failing to properly screen patients prior to admission.
The report cites three patients who were not pre-screened and later tested positive for Covid-19.
In seven of seven patient records reviewed the hospital had failed to ensure patients were tested prior to admission.
Other screening steps were absent in 12 of 26 records reviewed. Those missing steps included asking patients about any recent elevated temperatures or for other symptoms prevalent in Covid-19 cases.
In its plan of correction the hospital said it would no longer admit patients with positive Covid-19 test results.
In reviewing videos the surveyors observed multiple cases of employees interacting with patients while not wearing masks or not wearing them of other Personal Protective Equipment properly.
As part of its plan of correction the hospital agreed to maintain a list of non-compliant employees.
Contact: wfrochejr999@gmail.com

Stabbing Victim Waits 7 Hours for Doctor

By Walter F. Roche Jr.

A stabbling victim, whose case had been classified as urgent, had to wait nearly seven hours after arriving at a hospital emergency room before being examined by a doctor.
That was the finding of surveyors from the Pennsylvania Health Department performing a state licensure inspection of a Montrose hospital.
According to the report on the Endless Mountain Health System hospital the stabbing victim arrived at the hospital at 3:23 a.m. on March 1 with a stab would in the chest. Hospital staff had categorized the case as Level 3 Urgent.
Yet it wasn't until 10:09 a.m. when a doctor examined the patient and ordered a transfer to another hospital for surgery.
The physician "failed to evaluate the patient in a timely manner," the report states.
Hospital officials did not respond to a series of questions about the incident.
The Aug. 20 report also cited the hospital for failure to have a director of anesthesia and for a series of sanitation issues including dirt and dead bugs at the entrance to the emergency room.
The facility "failed to maintain a clean environment," the report states.
The hospital filed a plan of correction which included re-educating staff on triage policy and a monitoring program to ensure compliance.