PA Hospital Failed to Follow-up on Patient's Covid-19

This story was updated on Dec. 25 with comments from a hospital spokesman

By Walter F. Roche Jr.

A 188-bed Pennsylvania hospital failed to properly follow-up when a behavioral patient was diagnosed with Covid-19 five days after his admission.
In a 10-page report just made public this week, the state Health Department concluded that staff at the Allegheny Valley Hospital failed to provide adequate surveillance and take needed preventative action when the patient was diagnosed with Covid-19 on Oct. 25.
The unnamed patient was admitted on Oct. 21 and developed a fever on Oct. 24, the eve of his Covid-19 diagnosis.
After examining hospital records, the state inspectors concluded that in the days before the diagnosis, the patient had spent some 18 hours in the behavioral unit's hallway and six hours in the dayroom. He also spent more than 15 minutes with other patients while eating lunch.
Nonetheless hospital officials at the Natrona Heights hospital had concluded that none of the thirteen patients in the unit were at risk. No tests were administered, those officials concluded, because all of patientse tested negative at the time of admission.
The surveyors said a hospital employee who was involved in the followup to the diagnosis was unable to provide any documentation showing that contact tracing was completed.
In addition hospital employees told the health agency's surveyors that the conclusion that there was no risk of significant exposure was based on interviews but they were unable to name those purportedly interviewed. Finally a hospital employee (Employee 9) "admitted that contact tracing was not thorough."
The state surveyor also reported that they personally observed Allegheny Valley employees without proper masking.
In its plan of correction hospital officials said staff were re-educated on proper contact tracing procedures and that audits would be performed to ensure adherence.
The hospital said top infection control offficial met on Nov. 2 and "developed a comprehensive plan for identifying, reporting, investigating and preventing infections of communicable diseases" including Covid-19.
Dan Laurent, a hospital spokesman, said the hospital was preparing a more complete plan of correction which is expected to be filed with the state within a few days.
He added that the hospital had self reported the incident to state health official and informed the patient of what happened.
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Hospital Used Contaminated Testing Gear

By Walter F. Roche Jr.

A Pennsylvania hospital used contaminated gear for on internal test on an unsuspecting patient, according to a report from the state health department.
The report on Forbes Hospital, the second critical one to be released on the hospital in a matter of days, states that the same endoscope was used on a second patient without having been properly cleaned and processed.
In addition the state surveyors found that the incident was not "thoroughly investigated." The report states the facility "failed to ensure infection prevention processes were followed to prevent the potential contamination," the report states.
"Because of the foreign object inside the scope, the scope should be considered contaminated," the state health surveyors wrote in the report. The report does not indicate whether or not the patient exposed to the contaminated instrument was later found to be infected. A review of hospital records showed a letter informing the patient of what happened was not sent until Oct. 28, more than a week after the error was discovered.
In addition to the problem with the endoscope the inspectors found that a filter on equipment used in the cleaning process for storage of the endoscope had not been replaced at the proper intervals.
In fact, the report states, a worker who used the equipment was not even aware that it had a filter.
The hospital did not file an acceptable plan of correction and hospital officials did not respond to questions about the Oct. 20 incident.
In another recent report the 171-bed Monroeville hospital was faulted for letting a Covid-19 positive wait two hours in an emergency room before being seen.
Hospital officials did not respond to a request for comment.
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Einstein Cited for Involuntary Elopements

By Walter F. Roche Jr.

Involuntarily committed patients were able to walk away from a secured unit at a major Philadelphia hospital even though they were supposed to be under constant watch.
In a 28-page report on the Albert Einstein Medical Center, state surveyors concluded the medical facility "failed to substantially comply ... with professional standards of operation."
Calling the deficiencies "systemic" in nature, the officials from the state Health Department also cited the hospital for failing to mitigate ligature risks for behavioral patients at a known risk for suicidal ideation. One of those patients had previously jumped on rail tracks in a prior attempt.
Those suicide or ligature risks listed in the report included everything from window frames to gas outlets to pajama strings.
The report was made public on Oct. 31 even though the surveyors completed their report and site visit on April 23.
The hospital filed a plan of correction that calls for increased securiy with manned entrances and exits and inspection of all rooms to identify ligature risks.
Patient files and other hospital records showed four of four involuntarily committed behavioral patients were able to elope.
One patient apparently escaped by loosening a ceiling tile and moving a chair to gain access. While one patient was recaptured in another Einstein building the whereabouts of another patient was still "unknown" at the time of the report.
A third patient was observed slipping out a doorway but he had jumped into an elevator before he could be caught.
The fourth patient slipped away by following a social worker.
All were supposed to be under close observation during waking hours.
"A staff worker acknowledged there was no close observation," the report states in commenting on one of the elopements.
Hospital officials did not respond to a request for comment or to specific questions on the report.
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Covid-19 Patient Kept Waiting Two Hours

By Walter F. Roche Jr.

A patient at a Pennsylvania hospital, already diagnosed with Covid-19, was kept waiting for two hours in a hospital parking lot, when his oxygen ran out and he was forced to go to another facility.
The details of the case were included in a report recently made public by the state Health Department. Citing a federal law and state requirements, the Oct. 15 report concludes that the Chan Soon-Shiong Medical Center in Windber,PA. failed to provide required emergency care including a triage assessment.
The 54-bed facility, which was recently purchased by a foundation established by Patrick Soon-Shiong, the billionaire owner of the Los Angeles Times, also was cited for failing to even record the name of the patient in its records.
"There is no medical record for this patient," the state surveyors stated in their October report after examining hospital records.
According to the surveyors, who interviewed several hospital employees, the patient's girl friend was told to have the patient, who was having difficulty breathing, wait in the car in the hospital parking lot.
When the unnamed girl friend returned asking if the patient could finally come in or at least be triaged, she was sent back to the car.
When a staff member did finally come looking for the patient "the patient wasn't there," the report states. "The patient wasn't seen by an Emergency Room physician," the report continues.
The patient and the girl friend had left the parking lot when his oxygen ran out.
The state surveyors went to the unnamed other hospital where the patient was triaged, seen and immediately placed on oxygen.
The Windber hospital filed a plan of correction in which they said staff members would be re-educated on the requirements of the federal Emergency Medical and Emergency Leave Act and the state requirements for emergency care.
The plan, which was accepted by the state, also calls for new procedures to ensure all patients' names are entered in the log book known as the control register.
Request for comment from hospital officials went unanswered.
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CPR Halted Due to False Information

NOTICE: This story was updated on Dec. 13 with comments from a hospital spokesman By Walter F. Roche

Resuscitation efforts were abruptly halted on a patient at an Allegheny County hospital in early September due to erroneous information from a staff nurse about the patient's code status, according to a state inspection report.
A nurse, who had not completed competencies for emergency care, "incorrectly" told the physician administering CPR that the patient was in the "Do Not Resuscitate" category. The doctor then stopped the resuscitation efforts.
According to the five-page report on the 271-bed Forbes Hospital, the unnamed patient had been admitted to the hospital on Sept. 8.
The next day a hospital employee found the patient unresponsive.
"The patient was blue. He was found to be in VFib (ventricular fibrulation)," the report states.
A physician began to administer CPR (Cardio Pulmonary Resuscitation) but stopped when the unnamed nurse "incorrectly" stated that the patient did not want to be resuscitated.
The report does not state whether or not the patient survived.
The report on the Forbes Hospital concludes that the hospital failed to provide care in a safe setting.
Subsequent review of the patient's record "revealed there was no evidence of a DNR order," the report states.
The Monroeville hospital filed a plan of correction that includes immediate staff education sessions and audits to ensure that proper procedures were being followed. The plan also makes clear that the physician at the scene bears the responsibilty for determining whether CPR should continue.
Dan Laurent, a hospital spokesman, said the facility self reported the incident to the state and made full disclsoure to the patient's family.
Laurent also said the plan of correction has been implemented.
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Drugs Diverted from PA Hospital?

By Walter F. Roche Jr.

Leftover cocaine and lidocaine disappeared from a hospital in the Poconos and some of the lidocaine was diverted to a staff surgeeon, apparently for use in his off-site medical practice.
Those were the conclusions in a report from the state Health Dapartment on the Lehigh Valley Hospital - Pocono.
The recently released report on the 235-bed hospital in East Stroudesburg states that in four of 11 cases reviewed, there was no record that excess cocaine was properly disposed or wasted as required under the facilities own policies.
The cocaine cases occurred between July 8 and Sept. 7 of this year, according to the report.
The missing or excess lidocaine, the state surveyors learned during interviews with staff members, had been given to a hospital surgeon for use in his private practice.
The facility "failed to ensure excess lidocaine was not taken for personal use or use by others," the report states. The state surveyors noted that hospital records showing the disposal of the excess drugs did not exist.
In a plan of correction filed with the state, hospital officials said a face-to-face re-education session was held with the person responsible for handling the excess drugs.
In addition the hospital contacted the surgeon in person and by mail to immediately cease taking drugs from the hospital.
Hospital officials did not respond to questions about the report.
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Monitors Switched on Critical Patients

By Walter F. Roche Jr.

Staff at a Lancaster hospital mixed up the monitors assigned to two patients resulting in the wrong medications and tests being ordered for one of those patients, according to an Oct. 8 report from the Pennsylvania Health Department.
The incident occurred on July 20 at the 525-bed Lancaster General Hospital and involved two patients who were admitted around the same time and sent to the same telemetery unit.
The hospital's administrators "failed to adopt a policy directing staff how to identify which patient has which telemetry unit," the report states, adding that as a result medications and tests were ordered "based on the incorrect telemetry readings."
State surveyors in an October visit to the Penn Medicine facility found that hospital records showed one of the patients who had an irregular heart rhythm "appeared to simultaneously convert to a normal sinus rhythm upon arrival at the unit but patient was not actually in normal sinus rhythm."
The patient actually was still experiencing atrial fibrillation, the seven-page report continues, adding that the error was later discovered after nurses observed and conversed with the patients.
The report does not indicate if the mixup resulted in any adverse effects, but concludes that tests and medications ordered were based on the incorrect telemetry readings. Penn Medcine officials did not respond to questions about the report.
The state inspectors also faulted the facility for failure to maintain records showing which employee obtained the telemetry units and who placed them on the patients.
The hospital "failed to ensure nursing documentation was pertinent, accurate and concise," according to the report In a plan of correction filed by the hospital and accepted by the state, administrators said new systems had been put in place to ensure that the right monitor was placed on the right patient.
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State Home Cited for Splitting Elderly Couple

By Walter F. Roche Jr.

When they tried to take her husband of 58 years from their room at a state run nursing home, she barricaded herself in the front of the room and declared he wasn't going anywhere and she was in charge.
In the 27-page document that seemed more like the script of a tragic love story than an official state inspection report, the document details a series of events at the Hollidaysburg Veterans Center that led to the elderly couple's forced separation.
Though she had been declared competent and capable of making her own medical decisions, the trouble began in late May when the unnamed woman was observed giving her husband, a stroke victim, thin liquids when he was ordered thickened liquids.
On June 18 she was observed trying to feed her husband a cinnamon roll while he was lying down.
Staff tried to "educate" the woman that the patient shouldn't be fed in bed, the report states.
The resident "was upset and said she wanted to have a snack with her husband...She stated that she took care of her husband for five years after he had a stroke. She knew what he needed," the surveyors from the state Health department wrote.
In mid-June the woman clashed again with staff when she complained that there was no need to close a privacy curtain when they tended to her husband.
The woman however, noted that she also had power of attorney over her husband.
Staff then "educated" the woman that there was a need for a privacy curtain.
Finally the nursing home's Interdiscipllinary Team ruled that she was "not capable of making sound decisions and she was threatening his (her husband's) health and safety."
The team "decided that Resident 49 (the wife) should not room with Resident 27 (the husband)."
That led to the June 29 confrontation and the wife barricading the door to their room when they tried to take him away.
The staff then waited till the woman was away from the room and spirited Resident 27 to another room. When she returned she began going from room to room trying to find him. The woman then began refusing to take her medications, meals or other care.
She eventually found her husband's room but was told she couldn't go in because there were other males in the room and when she later returned to see him at bedtime she was told to say good bye from the doorway. The husband cried out when she appeared.
According to the report the women's health began to deteriorate as soon as she was separated from her husband.
On July 2 she suffered chest pains and shortness of breath and was sent to the hospital. She returned to the nursing home on July 7 "oriented." Her mood improved, but she was still angry.
In late July she was described as critically ill and in mid-August she was short of breath, pale, fatigued and had swelling in both legs, but refused to be hospitalized.
She and her husband were reunited briefly but he was moved out on Sept. 23 and his wife became depressed and had to be hospitalized once again.
The report from the state Health Department did not mince words and concluded that the staff actions resulted in physical and mental decline and hospitalization of a resident.
"There was no documented evidence that the facility included Resident 49 in decision making for Resident 27 and honored her decision, as Resident 27's power of attorney not to move Resident 27," the report states.
The facility filed a plan of correction in which it promised to revise the operations of its Interdisciplinary Team and establish new procedures to identify residents in decline.
Officials of the Department of Military and Veterans did not respond to questions on the report including the current status of the couple.
The report was the result of an inspection to recertify the 257-bed facility in the Medicare and Medicaid programs.
Other deficiencies included failure to follow infection control procedures when nurses in the unit housing confirmed and suspected Covid 19 diagnoses failed to change protective gear while going to different patients' rooms.
In addition the surveyors found several errors in the administration of insulin to patients. The injections were not made according to the schedule set by physicians.
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Patients Admitted Minus Covid Screening

By Walter F. Roche Jr.

Three patients were admitted to a Kingston, PA. behavioral hospital without a complete Covid-19 screening, according to a report recently made public by the state Health Department.
The report on the 149-bed First Hospital of the Wyoming Valley also disclosed that a patient who was not properly monitored after a fall was later found unresponsive and without a pulse.
That unnamed patient was rushed to a hospital, but the report does not disclose whether the patient survived.
"The facility failed to monitor a patient's vital signs and neurological needs were met following a fall," the report states, adding that the incident occurred in July.
The three patients not fully screened for Covid-19 were admitted in April, June and July. Hospital records indicated the patients were not asked a series of health questions, such as , "Do you have a fever or chills?.
Those items were just two of the deficiencies detailed in the report.
"First Hospital has implemented a plan of correction accepted by the Pennsylvania Department of Health following the recent inspection," a hospital spokeswoman said in response to a series of questions.
Other deficiencies cited in the state report include failing to ensure patients personal care items were secured and allowing an employee to continue prescribing drugs some seven years after the expiration of her U.S. Drug Enforcement Administration registration had expired.
The hospital responded by stating "with absolute certainty" that the records showed the employee, a physician assistant, did not prescribe any controlled substances during the relevant time period.
Still other items cited included 189 delinquent medical records some of which included patient records never completed by physicians.
The surveyors reported that there was no evidence any discipline was imposed on those who failed to complete those records.
In the plan of correction hospital officials said they had instituted new policies for the monitoring of fall victims and subsequently re-educated staff on those changes.
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Hospital Left Body in Morgue for 29 Days

By Walter F. Roche Jr.

The body of a deceased patient sat in a hospital morgue for 29 days and hospital officials failed to notify anyone, according to a report from the state Health Department.
In a report recently made public by the health agency, state surveyors said the body of the unnamed patient was placed in the morgue at UPMC Memorial Hospital on May 18, the date of death, and remained there for the next 29 days.
When family members called the 98-bed York hospital on June 19 they were at first told that the body was no longer there. But a subsequent check showed the body was still there and the family was subsequently notified.
Calling the case a violation of the state Medical Care Availability and Reduction of Error (M-CARE) Act, the surveyors said the hospital employees acknowledged that they had failed to file any type of event report or to make any arrangements for further disposition of the body.
The complaint investigation concluded the hospital "failed to maintain the security of a deceased body."
"This never happened before," one hospital employee told the investigators, adding they were aware the body had been in the morgaue for an extended period of time.
In hospital records, the report states, an employee had filled out a form stating "No family to inform."
The condition of the corpse had apparently deteriorated and the facility was cited for failure to maintain sanitary conditions."
In addition, according to the report, the patient's belongings had disappeared around the time of the transfer to the Intensive Care Unit.
"No one knows where MR1's belongings went. They went missing," the 10-page report states.
The hospital did file a plan of correction in which they described new procedures including a policy to forward bodies to the county coroner when they remain unclaimed for more than 48-hours.
The plan also calls for employees to notify superiors of any morgue/body hold issues and for education for staff members on the new procedures.
Hospital officials did not respond to questions including the ultimate disposition of the body.
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Suicidal Patient Absconds From Hospital

By Walter F. Roche Jr.

A suicidal patient under a court committment order was able to abscond from a Bucks County hospital due to a lack of security controls and adequate staff at the facility.
According to a nine-page report from the Pennsylvania Health Department the patient was later found hiding behind a bush on the grounds of the Grand View Health facility in Sellersville.
The patient had been involuntarily placed in the facility under a court approved commitment order issued after the patient apparently attempted suicide by overdosing on fentanyl.
"The facility failed to provide a safe environment," the report states.
As a result of the Sept. 1 incident state surveyors on Sept. 9 declared a state of immediate jeopardy, forcing the hospital to prepare an immediate action plan to address the lack of adequate staff and security.
That plan included the hiring of an outside firm, installation of new security and alarm equipment and ensuring that patients judged suicidal be placed under virtually constant observation.
One of the added features would provide a system to automatically lock all exits from the hospital simultaneously.
Despite those additions, the hospital still failed to comply with patient rights requirements, according to the report.
The state surveyors reported that the suicidal patient had complained earlier on the day of the incident about not being immediately released. Later the patient couldn't be located and a "Code Yellow" was declared.
The patient who escaped from the hospital had also been placed under a one-on-one watch, but was nonetheless able to walk away.
Hospital officals did not respond to questions about the report.
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Hospital Placed Patients in Danger

By Walter F. Roche Jr.

A 279-bed Pennsylvania hospital put two dozen patients in danger by failing to monitor the humidity in treatment rooms where surgeries and other procedures were being performed.
According to a recently released report on the Geisinger Wyoming Valley Hospital in Wilkes-Barre the surgeries and procedures went ahead in the Valley Medical Building even when the humidity was well above the recommended level of 30 to 60 percent set by the hospital itself.
"Based on the seriousness of the non-compliance and the effect on patient outcomes the facility failed to substantially comply" with state requirements, the report states.
Calling the excess humidity a "structural failure" the report states that each instance should have been reported to the state agency.
"The hospital must be constructed and maintained to ensure the safety of the patient," the report states.
Hospital officials did not respond to questions concerning the report. The hospital did however file a corrective action plan including new procedures to ensure compliance.
The treating physicians, the inspectors from the state Health Department stated, failed to make note of the excess humidity in 24 of 24 patient records reviewed. And the state reviewers noted the treating physician should have been informed of the humidity and then made a decision on whether to cancel the procedure. The corrective action plan calls for staff to inform the doctor or other provider of excess humidity levels prior to the procedure.
The high humidity, the report notes, increases the risk of infection.
The procedures included plastic surgery, general surgery, dental treatments and eye surgery.
The humidity levels reached as high as 80 percent. In two of the treatment rooms no temperatures or humidity levels were even recorded. The corrective action plan calls for the installation of temperature and humidity monitors in those two rooms.
The inspectors also found that two of the rooms had never been approved by the state for use in performing dental procedures.
The facility "failed to ensure a clean environment" in four treatment rooms, the state surveyors concluded, noting dust and debris seen during the inspection.
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State, Nursing Homes in Covid Dispute

By Walter F. Roche Jr.

Pennsylvania Health Department officals say 100 nursing homes have failed to report full data on Covid-19 cases while 56 more have submitted inaccurate data, but nursing home owners say it is the state that has the wrong numbers.
In what has been a growing dispute the state recently began adding to a weekly Covid-19 report the number of facilties that it contends have been submitting inaccurate data. The most recent report states that 7.94 percent of 693 facility operators submitted inaccurate data, while 14.43 percent failed to submit the required data.
Officials of the Pennsylvania Health Care Association, which represents nursing home operators, disagree.
"Providers have seen countless inaccuracies, discrepancies and errors in the numbers that are publicly reported by the Department, said Zach Shamberg, head of the association. Rather than "point fingers" Shamberg said, the association has been urging the state to work with nursing home operators to iron out differences.
But Maggi Barton, a spokeswoman for the state agency, said the discrepancies even included some nursing homes "inputting the number of deaths as their number of cases."
"We continue to strive to get more facilities to report, and report accurately," Barton added, disputing the claim that the state has not tried to work with actual operators.
She said when the data reported by a nursing home is "clearly inadequate we will mark as 'no data' to ensure we can reflect the most accurate picture of COVID-19 impact in these facilities."
Officials of the nursing home association say that when they've told the state their numbers were wrong the state made no corrections.
Some nursing home operators say that the problem may stem at least in part from the fact that the nursing homes have to report their data into two different reporting systems, which have differing definitions of reporting requirements.
They also contend that some of the nursing homes listed by the state as deficient, may have closed or changed ownership.
One thing both sides do seem to agree on is the public's need for accurate data. With the right data, Barton said, the state can "efficiently inform the public of the impact of COVID-19 on each facility."
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Breakthrough Covid Cases on the Rise in PA

By Walter F. Roche Jr.

Breakthrough cases, Covid-19 patients who got sick after being vaccinated, are on the rise in Pennsylvania, but state health officials say it is not unexpected or a bad sign.
According to data released today`by the state Health Department 69,822 breakthrough cases have been reported which represents about 9 percent of the state's total of 771,734 Covid cases. That compares with 35,389 breathrough cases reported in mid-Septemer.
In addition 3,247 Covid breakthroughs have needed hospitalization, which is about seven percent of the state's total hospitalizations.
Deaths among breakthrough patients have hit 518 in Pennsylvania or about seven percent of total deaths.
In September the agency reported 213 breakthrough patient had died and 1,820 were hospitalized, In statements released today, state health officials said the increase in breakthrough cases was not unexpected, but noted that the number of breakthroughs resulting in hospitalizations and death did not increase by a comparable amount.
Acting Health Secretary Allison Beam said the data shows that outcomes for the vaccinated who later suffer breakthroughs are much less likely to suffer death or hospitalizations.
Acting Physician General Denise Johnson stated that an increase in breakthough cases was expected as more residents are vaccinated.

Wilkes Barre Hospital Cited in Suicide Attempt

By Walter F. Roche Jr.

A patient at a Wilkes Barre hospital was able to attempt suicide even while being under a physician ordered one on one observation.
The Geisinger Wyoming Valley Medical Center also was cited for failure to develop a care plan for a patient with a rare psychological eating disorder that led to the eating of metal objects including a screw and a battery.
According to the Aug. 6 report from the state Health Department the first patient was admitted on July 16 with a history of suicidal thoughts.
Despite a physician's order that the patient be under one-to-one observation. a review of hospital records showed repeated instances in which there was no one assigned to observe the patient.
On July 26, for instance, there was no one on observation duty from 7:30 a.m. until 10:20 p.m.
That was just two days after the patient attempted suicide by removing the elastic band from a pair of pants. The individual was found with the face turned red and purple, the report states.
"The staff failed to perform a patient assessment following an attempt to self-strangulate," the report continues.
The patient was discharged on Aug. 2.
In the second case a patient with a specific psychological eating disorder, a desire to taste and ingest metal, was not provided with a treatment plan.
"The patient verbalized a craving for swallowing metal," the report states.
According to Health Department surveyors the patient attempted to ingest a number six half inch bolt and a hearing aid battery.
In its plan of correction the hospital said staff were educated on the one-on-one monitoring requirements and patient assessments. Re-education and monitoring were also promised for developing care plans for patients with eating disorders.
Geisinger officials did not respond to questions about the two citations.
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PA Veterans' Home Cited for Abuse, Neglect

By Walter F. Roche Jr.

Just two months after a similar finding, a state run nursing home for veterans has been cited for abuse and neglect in the care provided to two of its residents.
The August inspection of the Southwest Veterans Center in Pittsburgh concluded that the facility "failed to ensure two residents were free from physical abuse and neglect," according to the state Health Department report. In both cases an employee caused the patient injuries.
The incidents, the report continues, "caused actual harm."
Nursing home officials filed a plan of correction in which they reported that one of the employees had been terminated and that staff had been retrained on abuse and neglect issues. The state Department of Military and Veterans Affairs, which runs the state veterans homes, did not respond to questions about the two incidents.
The 236-bed facility was cited in July for failure to proprly investigate a case of resident- on-resident abuse.
The report, the result of an Aug. 4 complaint investigation, found that in one instance a patient who suffered from dementia and behavioral disturbances, was also known to wander.
A goal of his care plan was to ensure that he would not physically abuse other residents, staff or visitors."
On June 11 the resident was observed grabbing another patient's wrist then striking the employee in the upper left arm when the employee tried to separate them.
On June 18 the patient fell face down on a bed and was sent to a hospital for treatment of a facial laceration, requiring sutures, and a skin tear on the knee.
Though an employee claimed to have learned of the patient's injury only after the fall, video surveillance showed the employee forcibly pushed the patient into his room and then left to attend to another patient. Only then did he call a nurse reporting the patient was lying face down.
In addition the patient, who also suffered from dementia, was subsequently diagnosed with a mild stroke.
The employee was suspended once the videotape was reviewed and subsequently terminated. The patient, at the family's request, was discharged on June 23, according to the facility Plan of Correction.
In the second case cited in the report, a female patient suffered lacerations when the wheelchair overturned, apparently as a result of an employee mishandling the wheelchair. The worker also failed to place a helmet on the patient, state surveyors reported.
That employee, the report states, was retrained on wheelchair and helmet procedures and not suspended or terminated. The patient had the sutures removed and recovered.
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35,389 Pa Vaccinated Residents Got Covid-19

By Walter F. Roche Jr.

After weeks of insisting the data was not needed Pennsylvania officials have disclosed that 35,389 residents got Covid-19 even after being fully vaccinated.
The data released today shows 213 of the 35,389 died and 1,820 were hospitalized, according to the state Health Department. The data includes cases from Philadelphia.
The information on so-called breakthrough cases was included in an agency release urging all residents, who have not already done so, to get vaccinated.
Citing the fact that 97 percent of those who have contracted Covid-19 were unvaccinated, Acting state Health Commissioner Alison Beam said she was hopeful the data would lead to more residents getting the Covid-19 vaccine.
“With nearly seven million Pennsylvanians fully vaccinated, the data makes it clear: the vaccines are safe and effective at preventing severe illness from COVID-19,” Beam said at a Lancaster news conference.
Previously the agency limited its disclosures to only those breakthrough cases that led to hospitalization or death.
In issuing the data today the department said,"Tracking events of Covid-19 after vaccination is important for monitoring public health."
The statistics apply to Covid-19 breakthrough cases recorded since January of this year and include only those cases that occurred at least 14 days after full immunization.
State officials have stated that breakthrough cases are not unexpected because none of thee three available vaccines are 100 percent effective.
Contact:wfrochejr999@gmail.com Lancaster, PA - The Pennsylvania Department of Health's report on COVID-19 post-vaccination cases, commonly known as “breakthrough cases,” shows the overwhelming majority of cases, hospitalizations and deaths in the state are among the unvaccinated. “With nearly seven million Pennsylvanians fully vaccinated, the data makes it clear: the vaccines are safe and effective at preventing severe illness from COVID-19,” Acting Secretary of Health Alison Beam said today during a news conference at Penn Medicine Lancaster General Hospital’s Suburban Pavilion. “The overwhelming majority of the COVID-19 related cases, hospitalizations and deaths in Pennsylvania occurred in people who were not vaccinated,” she said. “In fact, the data shows that compared to unvaccinated people, fully vaccinated Pennsylvanians are seven times less likely to get COVID-19, and eight times less likely to die from COVID-19.” Penn Medicine Lancaster General Hospital’s Chief Clinical Officer Dr. Michael Ripchinski agrees. “While masking and social distancing will help to reduce the risk of becoming infected and transmitting COVID-19, vaccines are the most effective way to protect those who are vulnerable, including the immunocompromised, and our children who are too young to get the vaccine.” The Centers for Disease Control and Prevention defines post-vaccination cases as individuals who are fully vaccinated and tested positive for COVID-19 more than 14 days after they completed their full one-dose or two-dose vaccination series. They are also referred to as vaccine breakthrough cases. Today’s online report shows that since January 2021: · 97 percent of COVID-19-related deaths were in unvaccinated or not fully vaccinated people. Among a total of 6,472 COVID-19-related deaths identified in Pennsylvania in 2021, the latest data shows 213, or three percent, post-vaccination deaths identified. Cumulative death incidence among the unvaccinated and not fully vaccinated was 7.9 times as high as the death incidence among the fully vaccinated. · 95 percent of reported hospitalizations with COVID-19 as the primary diagnosis/cause of admission were in unvaccinated or not fully vaccinated people. Among a total of 34,468 hospitalizations with COVID-19 as the primary diagnosis/cause of admission reported in Pennsylvania, 1,820 were reported to have occurred in fully vaccinated people. These figures account for data from 55 percent of all hospitals and 69 percent of acute care hospitals in Pennsylvania, representing approximately 80 percent of acute care beds in the state. · 94 percent of reported COVID-19 cases were in unvaccinated or not fully vaccinated people. Among a total of 639,729 positive cases, there have been 35,389, or six percent, identified post-vaccination cases. Cumulative case incidence among the unvaccinated and not fully vaccinated was 7.1 times as high as the case incidence among the fully vaccinated. “That means that 97 percent of deaths reported through the beginning of September were in unvaccinated or not fully-vaccinated people,” Beam said. “This data is further proof that the vaccines are our best tool to protect ourselves against the virus, keep our children learning in schools, keep our workforce in-person, and foster social and economic recovery,” she said. “Every person who chooses to get vaccinated brings us a step closer to moving past the pandemic.” As the number of COVID-19 cases in Pennsylvania is surging to more than 3,000 per day, doctors at numerous hospitals across the state recently began publicly discussing the number of patients in their facilities. Penn State Milton S. Hershey Medical Center reports that 95 people are hospitalized with COVID-19 today; 28 are in the ICU. “Penn State Health is seeing some breakthrough COVID-19 cases but they are typically patients hospitalized for something else who test positive when they come in for treatment,” said Dr. Fahad Khalid, chief of hospital medicine. “Vaccinated patients typically don’t develop severe COVID-19 or need intensive care. However, about half of the unvaccinated COVID-19 patients here need intensive care, compared to less than one-quarter during earlier surges.” UPMC also reports an increase in patients hospitalized with COVID-19, with nearly 440 patients across the system on Monday. “Over the past several weeks, we have seen as much as 19 times more non-vaccinated patients ages 50 and younger admitted to UPMC hospitals compared to vaccinated patients,” said Dr. Donald Yealy, chief medical officer at UPMC. “Vaccination is crucial at this time. Our urgent plea is for everyone eligible for a vaccine to get one.” In addition to the influx of COVID-19 patients, Dr. John Williams, chief of the Division of Pediatric Infectious Diseases at UPMC Children’s Hospital of Pittsburgh, recently reported at a UPMC press briefing, “We are seeing an increase in outpatient pediatric COVID-19 cases in clinics and emergency departments and an increase of children needing hospitalization because of COVID-19. These young children are at a higher risk for becoming infected now than any other time during the pandemic.” He noted that, “In states where vaccinations are low, hospitalizations of children are four times higher than in states where vaccination of children is high. Fortunately, we know how to keep kids safe: masking, vaccination of everyone over 12, and testing.” “I truly hope that this data encourages everyone who has not yet been vaccinated to speak to their doctor about getting the vaccine as soon as possible to protect themselves and people around them,” Beam said. Post-vaccination data is now posted online at: PA Post-Vaccination Data. MEDIA CONTACT: Mark O'Neill - ra-dhpressoffice@pa.gov # # # Read More Please note: you are receiving this email because you have subscribed to receive updates for Department of Health Press Release Listserv on the DOH website. To unsubscribe, or to find additional subscriptions available from the Commonwealth of Pennsylvania, ple

Handicapped Patient Suffers 3rd Degree Burns

By Walter F. Roche Jr.

A severly handicapped blind patient in a city owned nursing home suffered third degree burns when she was left alone with a scalding cup of soup.
According to a report from the state Health Department, the patient who was suffering from dementia and multiple other ailments, was left "unsupervised and unassisted" even though nursing home records stated that she needed assistance from at least two staffers to eat.
The patient was "totally dependent on staff for locomotion" the report states. "The lack of supervision and assistance resulted in actual harm to the resident who sustained second and third degree burns from a hot liquid spill," the nine-page report states.
"It hurt really bad when the spill happened. I screamed," the victim told surveyors from the Health Department.
The investigation showed that when the patient asked for some soup on June 20 a nurse heated up a cup of water and mixed it with the soup and then microwaved it. She placed the styrofoam cup of hot soup on the patient's table and told her to wait ten minutes before trying to eat it. Then she left the room.
Though the patient was supposed to be placed in a set position while eating, that never happened.
A review of the nursing home records showed that by facility policy, "under no circumstances would a hot liquid be served to a resident in a styrofoam cup."
After the nurse left, the patient subsequently tried to adjust the table thus tipping over the cup which then spilled the scalding liquid on her legs, buttocks and abdomen.
The patient screamed in pain, according to the report, and blisters were found on her buttocks.
She was sent to a local hospital burn center where she was diagnosed with second and third degree burns. She later underwent surgery to debride the burnt skin followed by skin grafts.
"The lack of supervision and assistance resulted in actual harm to Resident 1 who sustained seond and third degree burns from a hot liquid spill," the report states.
Nursing home officials filed a plan of correction in which they stated that special adaptive devices were being provided for the patient and staff were re-educated on procedures to be followed with a patient with multiple disabilities.
James Garrow, spokesman for the city Health Department, which oversees the home's operatons, said the plan of correction had been implemented and accepted by the state in a followup visit.
He said privacy concerns barred the agency from discussing individual cases.
The report comes as the city owned facility has reported to the state that 19 of its patients have died from Covid 19. Contact: wfrochejr999@gmail.com

Pottstown Hospital Delayed Adverse Reports

By Walter F. Roche Jr.

Officials of the Pottstown Hospital failed to promptly report adverse and serious events including an assault by a patient which wasn't reported for a month.
The delayed reporting was uncovered during an annual licensure survey by the state Health Department in mid-July.
Citing multiple violations of the state Availability and Reduction of Error Act, the report cites two cases in which there were complications following surgery or an invasive procedure. The two cases came in June and July.
The serious events are supposed to be reported within 24 hours of their discovery, the report notes. An assault by a patient that occurred on May 6 was not reported to the state until June 7, the state surveyors reported.
Pottstown, a 219 bed facility, is owned by Tower Health, a financially troubled company which has been actively trying to sell off hospitals it purchased from Community Health Systems in 2017.
Other delayed reports included a fall which occurred on April 9 but wasn't reported until April 12. An EKG that was mislabeled on March 28 was not reported until April 9. A patient elopement on April 30 was not reported until May 30.
In another citation, surveyors reported that hospital records showed a patient was kept in the emergency room for more than six hours resulting in an "infrastructure failure." Two cases involving blood transfusions were cited in the report due to the failure of hospital to follow established procedures.
In one case hospital employees failed to check for vital signs 15 minutes after a transfusion was initiated. In the second case the blood flow was not increased after 15 minutes as required under hospital procedures.
In its plan of correction the hospital said it had established a procedure to ensure adverse events were properly reported. Adverse events will also be reported to the patient safety committee.
The plan calls for re-education of staff on proper blood transfusion proedures and establishment of an audit system to ensure future complaince. The hospital also promised to develop a labeling system to ensure surgical instruments can be tracked back to a particular patient in the event of an adverse event.
Tower Health did not respond to requests for comment.
Contact: wfrochejr999@gmail.com

Closures Hit Personal Care, Assisted Living

By Walter F. Roche Jr.

Some 35 personal care and assisted living facilities in Pennsylvania have closed their doors during the ongoing pandemic but state officials say the number of available beds have actually increased over the same period.
The closures are noted in periodic reports posted by the state Health Department. Industry experts say the closings may be due to a variety of factors and not just the Covid-19 pandemic.
"While we do not collect data on the reason for a facility's closure, we are hearing that COVID is just one reason for closures. Others include the labor shortage, facility plant issues, and retirements," said Brandon Cwalina of the state Department of Human Services.
He said that it appears that most of the closures were among smaller facilities that primarily serve recipients of the Supplemental Security Income program.
Offsetting the closures he said were new larger facilities that opened during the same time period.
In February of 2020 there were 64,731 personal home care beds available and 4,195 assisted living slots. In July of this year the personal care beds jumped to 65,404 while assisted living beds reached 4,984.
He said that while the facilities that closed generally had 20 or fewer beds, the larger ones that opened had 70 or more slots.
Though the facilties that closed were not among its members, officials of the Pennsylvania Healthcare Association (PHCA), which represents nursing homes along with asssisted living facilities, said they were aware of an uptick in shutdowns.
"Much like all of long-term care, there is a workforce problem and it’s our understanding that staffing played into the reasons for these closures. Funding to support operations and staffing could also be a factor," said Eric Heisler of the PHCCA.
Citing the staffing issues Heisler said that could likely lead to facilties limiting admissions and creating access problems. Since the closed facilties primarily served SSI recipients, they would be the one impacted, he added. "The staffing concerns are also being felt at the nursing home level and it is also causing an access to care issue as providers are limiting admissions based on the amount of workers they have to meet the state’s requirements," he concluded.
Contact: wfrochejr999@gmail.com

A Worthy Disinterment ?

By Walter F. Roche Jr.

For years the family grave of the man considered by many to be the father of Tennessee law and history has remained behind a car repair shop along a commercial strip in Nashville.
Now a petition in Davidson Chancery Court seeks to have the body of John Haywood, his wife and possibly more family members disintered from the site along Nolensville Pike and moved to Nashville's historic cemetery.
Hal Hardin, a Nashville lawyer who filed the petition, said the city cemetery, will be a good and better fit for the self educated former Supreme Court Justice who died in 1826 while still sitting on the bench.
Born in North Carolina in 1753, Haywood was admitted to the North Carolina bar in 1786 and later served as Attorney General and still later as a superior court judge.
He subsequently went in to private practice and was the author of legal scholarly works on the laws of Tennessee and North Carolina.
He later moved to Tennessee where he already owned land in Tusculum. After building a home and two log cabins he began teaching law to aspiring students, creating what was believed to be one of the first law schools in the region.
He was appointed to the Tennessee Supreme Court in 1816.
Citing recent trends in historical graveyards, Hardin said the petition was prompted by concerns that the graveyard might be permanently locked at its current location.
Calling Haywood "a legal pioneer," Hardin said that thus far he has only been able to identify two of the Haywood family's ancestors.
Mary Beth Hayes, one of those two, said she supports the petition.
"Yes, as a distant descendant of Judge John Haywood, I do support the re-interment of John Haywood, his wife Martha Haywood, their family members, and any enslaved people from their current site located within a commercial development near Nolensville Road to the Nashville City Cemetery," she wrote in an email response to questions.
Hardin said it is known that Haywood's wife Martha is buried at the current site along with other family members.
He said Middle Tennessee State University has agreed to analyze the remains recovered from the Nolensville Road site. He said the city cemetery has agreed to provide the site for reinterment.
"We are trying to scrape some money together to cover remaining costs," Hardin concluded. He noted that any further development at the current site is barred while bodies are buried there.
The land is owned by Polly Properties, based in Texas. The company's Tennessee lawyer did not respond to requests for comment.
According to court filings legal notices of the proposed disinterment are ongoing and, thus far, no opposition has surfaced.
Contact: wfrochejr999@gmail.com

Veterans Home Cited in Multiple Falls

By Walter F. Roche Jr.

The same state run nursing home where 42 patients died in a Covid-19 outbreak this year has been cited by Pennsylvania regulators for failing to take corrective action when the same patient fell four times, two of them resulting in actual harm - hip fractures.
A report issued this week on the Southeastern Veterans Center in Chester County said the the falls occurred between March 29 and May 29. The first and last landed the patient in a local hospital with hip fractures.
The seven-page report notes that because of the falls the patient could no longer get out of bed or walk without assistance.
The state Health Department surveyors were actually in the 238-bed facility on the day of one of the falls and observed the patient lying on the floor in the dining area.
In all four cases, the report states, officials of the state run home failed to thoroughly investigate the incidents and take steps to avert yet another fall.
Though it is now under different management, the home has been cited for multiple violations in the deaths of 42 patients from Covid-19 earlier this year.
The facility's management filed a plan of correction in response to the latest July 16 report in which it promised to review and conduct root causes analyses on all patient falls. Officials of the state Department of Military and Veterans Affairs, which runs the home, did not respond to questions about the report.
The lack of action on the multiple falls came despite the prior determination that the patient was at high risk of falling and was in severe cognitive decline.
According to the report on March 29 a staff nurse heard a loud noise around 4 p.m.The patient was found on the floor near the bathroom. He complained of leg pain and was ultimately diagnosed with a hip fracture requiring surgery.
On his return, the surveyors reported, no new interventions were initiated to prevent future falls and there was no final determination of the cause.
Two Other falls, apparently without injury, were reported on April 8 and early May. Though a special wheel chair had been promised, he never got it.
After the May 29 fall the patient reported pain in his left hip and wrist and was sent to the hospital for surgery.
"The facility failed to thoroughly review, determine the cause and develop new or effective fall preventions after the fall," the report concludes, noting that the March 29 fall "resulted in a decrease in transfer and walking ability."
Contact: wfrochejr999@gmail.com

Patient Dies Awaiting Emergency Care

By Walter F. Roche Jr.

A patient in a hospital emergency room died awaiting treatment after hospital personnel failed to even connect him to a heart monitor.
The May 30 incident at the 30-bed Conemaugh Miners Medical Center in Hastings was detailed in a June 29 report on a complaint investigation.
The hospital "failed to implement emergency treatment and procedures in a timely manner," the 10-page report states.
The unnamed patient arrived at the medical center at 8:15 a.m., complaining of two days of vomiting, diarrhea and stomach cramps.
While he was awaiting an IV, the patient asked to go to the bathroom but became unresponsive when a staffer attempted to put him in a wheelchair.
The report says the patient was then brought back to his room in the emergency department. Thirty minutes of CPR was unsuccessful.
The report states CPR was abandoned "due to medical futility."
According to the report the patient was not placed on a monitor until the patient coded at 9:30 a.m. The monitor had been ordered at 8:40 a.m.
"There was no monitor strip to view at all and the patient did not have an EKG," the report states.
Staffers at the Conemaugh Health System facility told state surveyors there was no blood pressure recorded because they were unable to get one, but that failure was not documented in the patient record.
State surveyors were told the staff was "fairly new and was nervous about getting respiratory supplies gathered for intubation."
During the CPR effort the wife of the patient took over when the nurse became tired, the report states.
"There was a bit of a delay in getting it all together," the report states.
In its plan of correction, medical center officials said staff would be re-educated on the need for obtaining vital signs and establishing the patient's severity index number at the time of admission.
Hospital officials did not respond to requests for comment,
The hospital "failed to provide good quality care," the report concludes.
Contact:wfrochejr999@gmail.com

Hospital Improperly Turned Away 2 Patients

By Walter F. Roche Jr.

A Blair County hospital has been charged with violating a federal law when it turned away patients brought to the 25-bed facility for emergency treatment.
In a report recently made public the state Health Department said the Penn Highlands Tyrone facility turned away a patient who had been brought by ambulance on April 12.
A second patient, according to the report, was turned away on Nov. 11, of last year.
The state surveyors, who were conducting a special monitoring review on June 28 and 29, said both patients were in effect, improperly transferred.
"Every hospital must institute essential life saving measures and provide emergency services that will minimize aggravating the condition of the patient during transport when referral is indicated," the report states.
In one of the cases an emergency room physician greeted the ambulance and turned it away before the patient could be unloaded.
The report cites the federal Emergency Medical Treatment and Labor Law, which requires hospitals to perform a screening examination and stabilize a patient prior to transfer.
"The facility could provide no documentation that a medical screening examination was performed," the report states.
In addition to the failure to examine the hospital was cited for failing to enter the patient names into an emergency room control log book required under the same federal law.
In addition, the survey found the hospital failed to properly transfer the two when it failed to notify the receiving facility in advance.
The hospital did not respond to requests for comment and it failed to file an acceptable plan of correction with the state.
Contact: wfrochejr999@gmail.com

PA "Urges" Vaccinations for Nursing Home Employees

By Walter F. Roche Jr.

Pennsylvania health officials say it is not an order but they are urging nursing home operators to get at least 80 per cent of their employees vaccinated by Oct. 1.
The request comes as more than 8,400 Pennsylvania nursing home residents have died of Covid-19 since the beginning of the ongoing pandemic.
Deputy Health Secretary Keara Klinepeter said that currently only 12.5 per cent of the state's nursing homes have 80 per cent of their staffers innoculated against Covid-19.
Calling it "an expectation," Klinepeter hinted that further actions may be taken against those facilities not meeting the Oct. 1 deadline.
She said the state would require those homes not meeting the goal to do more frequent testing.
State and federal officials have stated repeatedly that unvaccinated employees are the primary source of infections among nursing home residents.
She said the 12.5 per cent was "not enough from a public health perspective to prevent future outbreaks of the virus."
Agency officials reported earlier this week that at least 8,477 residents of state nursing homes have died from Covid-19 and the actual number may be substantially higher.
The figure is based on the deaths self reported by the facilities and many facilities have not been consistently updating data.
Contact: wfroche999@gmail.com

Temple Hospital Cited in License Review

By Walter F. Roche Jr.

Temple University Hospital, which already has been the subject of recent unfavorable inspection reports, has been cited for mutiple deficiencies in an annual licensure survey.
In a 37-page report released by the state Health Department the Philadelphia facility was cited for failing to protect the privacy of patients and failing to secure those patients'confidential health records.
State surveyors witnessed from a hallway a patient having a breathing tube removed in full view of a patient across the hall. A privacy screen was not drawn, according to the report.
In the same hallways surveyor found unattended work stations displaying the confidential health records of patients. One of the records on display was for a mother and her newborn child.
The displayed information included the location of the baby.
The surveyors also found the hospital had instituted new services without following proper procedures and notifying the department 60 days in advance. Those services included the use of new fall-prevention beds and use of a remote video patient monitoring system.
In its plan of correction Temple said the new beds and the monitoring videos were taken out of service until proper approvals could be obtained.
The report also cites a complaint filed by the family of a patient, who was discharged without the prescribed medication. Though the family was told the medicine would be delivered the next day, a family member had to come to the hospital to get the medication.
Also criticized were the hospital's infant formula preparation operations. The surveyors found the hospital did not meet the requirement that a registered nurse or a professional dietitian be in charge of infant formula preparation.
The hospital's plan of correction states that a professional dietitian had been hired to oevrsee formula preparation. The hospital also reported it had switched to the use of sealed pre-made formulas for some patients.
Yet another deficiency cited was the failure to achieve a goal of 90 per cent compliance with staff handwashing requirements.
The hospital did not respond to a series of questions about the critical report.

PA. Nursing Home Covid Deaths Top 8K

By Walter F. Roche Jr.

The number of Pennsylvania nursing home residents who died of Covid-19 has reached at least 8,477, and the actual number could be much higher.
Maggi Barton, spokeswoman for the Pennsylvania Health Department, said Monday that total comes from data self reported by the nursing homes.
Barton said that some nursing homes had not reported Covid death data by Aug. 3, the date of the last compilation.
"There were a number of nursing homes who did not report," Barton said, adding that the exact reports by several other homes were automatically redacted if the total was less than five.
In addition to the nursing home Covid deaths another 1,870 deaths were recorded in personal care facilities licensed by the state Department of Human Services.
She said the same caveats applied to the personal care facilities. The data was self reported and reports with less than five deaths were automatically redacted.
"We continue to work with these facilities to report in order to present the most accurate data to understand COVID-19 impact on these communities," Barton said.
The data posted on the state Health Department web site shows 13 nursing homes have reported 60 or more deaths while two have reported more than 100.
The Neshaminy Manor in Warrington and the Northampton County Home Gracedale reported 104 each.
The Fair Acres facility in Lima reported 97 Covid-19 deaths and Conestoga View in Lancaster reported 81. Cedarbrook in Allentown and Brighton Rehabilitation reported 83 deaths each. Conestoga View was recently sold and renamed the Lancaster Nursing and Rehabilitation Center.
Contact: wfrochejr999@gmail.com

Hospital Sued Over Abandoned ER Patient

By Walter F. Roche Jr.

Six days after a patient died after being literally abandoned in the emergency room of the WellSpan York Hospital, the hospital's president wrote to his family assuring them the patient had received prompt and approriate care.
In fact the patient sat slumped over in a wheel chair for more than two hours before he was finally found unresponsive.
Those facts were spelled out in a 49-page suit filed in York Common Pleas Court this week.
The malpractice and wrongful death action was filed for that patient, 72-year-old Terry L. Odom and his son, Terry R. Murray.
According to the suit, Odom was brought to the hospital by ambulance at 10 a.m.on Aug. 16, 2019 but failed to get any serious medical attention till 12:25, when he was found unresponsive. He could not be revived and was pronounced dead at 1:31 p.m.
Citing the "shocking and appalling abandonment" of Odoms, the suit states that hospital staffers passed his wheelchair at least a dozen times without even looking at him.
He had been placed in the emergency department waiting room at 10:25 a.m. without any detailed examination.
The nurse, serving both as a pivot nurse and triage nurse, never even got out of her seat to look at the patient.
Citing the chronic understaffing in the hospital's emergency room, the suit charges that hospital officials placed profits over patient safety thus leading to a preventable death.
The death was "due to the outrageous and recklesss actions of WellSpan," the complaint states adding that WellSpan knew for at least a year that the emergency department was "dangerously understaffed."
The suit states that when Odoms arrived at the hospital the ambulance crew informed hospital staffers that the patient had been placed on oxygen because of dangerously low oxygen saturation levels.
The oxygen was removed and never replaced.
Sometime before 12:25 a.m. he suffered a cardio respiratory event, but not before surveillance cameras showed him stretching out his arms in a plea for help.
When he was finally discovered slumped over in a wheelchair "He was right where they had put him but incapacitated and unable to respond." By then the emergency room staff had made a notation in his record LWBS (Left Without Being Seen).
Contact: wfrochejr999@gmail.com

Hospital Cited on Transplant Documentation

By Walter F. Roche Jr.

For the second time this year a Pennsylvania hospital has been cited by state surveyors for failing to properly document organ donations from deceased patients.
In a June 4 report recently made public by the state Health Department surveyors faulted the Evangelical Community Hospital in Lewisburg for failing to have required documentation of transplants from deceased donors to a local organ bank.
The report notes that similar deficiencies had been cited in a January report on the hospital.
Despite submitting a plan of correction in January designed to prevent repeat citations, similar deficiencies were found again in June.
The 162-bed facility "failed to correct its deficient practices related to organ procurement documentation and failed to implement the plan of correction as submitted by the facility and approved by the department," the report states.
Files in three of three cases reviewed had deficiencies, according to the surveyors. Evangelical isn't alone. UPMC Muncy was also recently cited for transplant program deficiencies.
An Evangelical Hospital spokeswoman, Deanna Hollenbach, said the hospital did follow proper procedures.
"The June report from the Department of Health refers to a documentation issue where the proper paperwork was completed and processed but not scanned into the patient chart," Hollenbach wrote in an email response to questions. "All actual organ/tissue donations were done as required by law and all referrals were made," she added.
As it did in January, the hospital's plan of correction calls for staff to be re-educated on transplant record requirements.
The recent deficiencies were noted in three patients, two who died in March with one more in May.
The facility "failed to complete the certificate of referral in three of three medical records reviewed," the report states.
"All Gift of Life referrals will be kept by the nursing supervisor," the plan of correction states.
A month earlier UPMC Muncy was cited for failing to have a signed consent form in the record of a deceased patient whose eyes and skin were donated to an organ procurement agency.
Contact: wfrochejr999@gmail.com

PA Recorded 13,411 LTC Deaths

By Walter F. Roche Jr.

The Covid-19 death toll among residents in Pennsylvania long term care facilities has hit 13,411, according to data compiled by the state Health Department.
The agency said Thursday the deaths at nursing home and personal care facilities were among 72,242 residents at those facilities who were sickened by the coronavirus.
The state health agency also reported 15,624 employees of licensed nursing homes and personal care homes were diagnosed with Covid-19.
Other records from the agency show some 20 nursing homes reported 50 or more Covid-19 deaths since the pandemic began well over a year ago.
The most deaths, 103, were reported at the Neshaminy Manor in Bucks County. Two facilities, the Gardens at West Shore and Rosewood Gardens in Broomall each reported 50 deaths.
Others with more than 50 deaths include Conestoga View in Lancaster at 81, Fair Acres in Lima-97, Cedarbrook in Allentown-83 and Cambria Care Center with 84.
Still other facilities with more than 50 coronavirus deaths include Berks Heim in Berks County with 68, Allied Services in Allentown-65, Centre Crest in Bellefonte-74, Manor Care in Sinking Springs-60, Cedar Haven of Lebanon-68 and Brighton Rehabilitation of Beaver 77. The state health agency also reported 15,624 employees of licensed nursing homes and personal care homes were diagnosed with Covid-19.
Contact: wfrochejr999@gmail.com

New Process Speeds PA Hospital Upgrades

By Walter F. Roche Jr.

On June 4 of this year surveyors from the Pennsylvania Health Department visited the Geisinger Medical Center to verify that the recent replacement equipment and new services at the facility were in compliance with state requirements.
The visit came one day shy of a year after the state agency instituted a new process for approving hospital requests for replacement equipment and new services.
Due to the new process Geisinger didn't have to wait for the state's sometimes overwhelmed surveying staff to make a site visit before actually putting the replacement equipment or new services in to operation. Recent attestations submitted by Geisinger include speech therapy services and a system to control post partum complications.
Under the new procedure, which went into effect June 5 of last year, the health facility filled out and submitted to the state an attestation certifying that the equipment was properly installed and in compliance with state requirements.
Sixty days after that notification the new services or equipment could go into operation, the department announced in 2020.
"Prior to this a facility would have to wait... and that could take time," Maggi Barton, the agency's deputy press secretary wrote in response to questions. The goal, she added, was greater efficiency.
The agency said in an announcement of the change, "We recognize that the demand for surveys has outpaced our staffing resources, which, on occasion has left hospitals waiting."
If the health facilities attestations are found wanting when surveyors make a site visit, that could trigger further reviews of other attestations, according to the state policy. While new services and replacement equipment can come under the speedier process, attestations cannot be used for renovations or new construction.
Contact: wfrochejr999@gmail.com

PA Hospital Failed to Report RN Drug Incident

By Walter F. Roche Jr.

A Renovo hospital has been cited by the state Health Department for not properly reporting that an agency nurse had been caught diverting narcotic drugs and was under the influence while on duty.
The report on the Bucktail Medical Center states that the nurse was caught on Oct. 16, 2020, but the information wasn't reported to the Patient Safety Authority until June of this year.
The report notes that under Medical Care Availability and Reduction of Error Act, such an incident should have been reported within 24 hours of its discovery.
In addition the hospital, which describes itself as a 23-bed critical access hospital, failed to report the matter to the state Attorney General's office.
A review of meeting minutes of the hospitals governing board showed the fact that a nurse had diverted and tampered with narcotic drugs was discussed at a subsequent meeting of the facility's governing board.
The facility also failed to report that the hospital had gone on lockdown on March 2 of this year. The lockdown was triggered by the report of a shooter in the area.
The lockdown, which prevented patients or visitors from leaving or entering the building, was also belatedly reported to the state.
The hospital filed a plan of correction in which it promised to properly report unusual incidents both internally and externally.
Hospital officials did not respond to a series of questions on the report.
Other items in the report included the failure of two board members to file annual conflict of interest reports, food not being kept at proper temperatures, and missing continuing education requirements.
Contact: wfrochejr999@gmail.com

Critical Test Results Held Nine Months

By Walter F. Roche Jr.

A Bucks County hospital didn't tell a patient or the treating physician about "a signficant abnormality" that turned up in test results until nine months after the test had been performed, according to Pennsylvania Health Department records.
In a four-page report just made public the agency said Aug. 17, 2020 CAT scan results from the Grand View Hospital showing a 3.4 centimeter "enhancing mass" on the patient's left kidney were not provided to the patient and the doctor who ordered the tests until mid-May of this year.
When it did finally provide the patient with the test results, the Sellersville hopital advised the patient to see his doctor "as soon as possible."
A hospital spokeswoman, Wendy Kaiser, said the hospital had self-reported the incident to the state and the facilty's plan of correction in response to the survey had been accepted. She did not respond to several other questions including the current status of the patient.
The Health Department report states that the report was the result of "an unannounced Special Monitor survey."
An addendum to the original 2020 test report states,"The patient will be receiving a notice as a result of a determination by your diagnostic imaging service that further discussion of the test results are warranted and would be beneficial to the patient."
The hospital records note that the finding is "consistent with renal neoplastic disease" or cancer.
The report concludes that the hospital violated the state Patient Test Result Information Act which mandates that imaging entities directly inform patients or their designees of test results showing "significant abnormalities."
In a plan of correction filed by Grand View, hospital officials said re-education programs were held to remind radiologists of reporting requirements and audit would be conducted to ensure that test results were being reported as required.
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Compounding Drug Recall

US Food and Drug Administration Innoveix Pharmaceuticals, Inc. Issues Voluntary Recall of All Sterile Compounded Drug Products Due to A Lack of Sterility Assurance Innoveix Pharmaceuticals, Inc. is voluntarily recalling the following lots of sterile compounded drug products, within expiry. The products are being recalled due to a lack of assurance of sterility. These concerns arose following a routine inspection of the pharmacy by FDA. Administration of a drug product intended to be sterile, that is not sterile, could result in serious infections which may be life-threatening. To date, Innoveix Pharmaceuticals, Inc. has not received any reports of adverse events related to this recall. This voluntary recall is being conducted out of an abundance of caution and to promote patient safety, which is the pharmacy's highest priority. The affected products are injectable Semorelin / Ipamorelin 3mg and injectable AOD-9604 3mg. The products can be used for various indications as prescribed. The products can be identified by an Innoveix Pharmaceuticals, Inc. label.

State Home Failed to Control Resident

By Walter F. Roche Jr.

Staff at a state run nursing home for veterans failed to control a resident who engaged in bizarre behavior and became belligerent and combative when anyone tried to re-direct him.
"The facility failed to report, investigate and monitor potential resident-to-resident incidents" states the May 25 report on the Southwest Veterans Center in Pittsburgh.
According to the state Health Department report, the unidentified resident would go into another resident's room, dressed or undressed, and then get into the other resident's bed, whether the other resident was already in the bed or not.
Staff attempts to redirect the resident triggered "very belligerent and combative" behavior, the report states.
The report notes that the resident apparently suffered from Sundowner's Syndrome, a condition not uncommon among dementia patients. Those suffering from the condition may become confused and combative later in the day.
The nursing home was faulted for not reporting the incidents to the state despite the fact that at least 11 staffers were aware of the resident-on-resident incidents.
The resident had been admitted in early March with a diagnosis of vascular dementia yet the facility had failed to develop a care plan to address his behaviors.
In a plan of correction filed by the nursing home, officials said that the resident was moved to a private room and checks on the patient were made every 15 minutes.
The state surveyors had found that staff failed to perform those checks on three days in mid-May.
The Health Department report also cites the facility for failing to obtain physician authorizations for patients requiring dialysis.
For one patient there were no physician authorizations for two full months.
Another state run veterans nursing home in Scranton was cited by state surveyors for failing to investigate a possible case of patient abuse.
The patient's daughter had complained that her father had a bruise on his back when he was taken to a hospital emergency room. The daughter reported the bruise to nursing home officials but it was never investigated.
Officials of the state Department of Military and Veterans Affairs, which runs the homes, did not immediately respond to questions about the reports.
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Hospital Lacked Donor Organ Consent Form

By Walter F. Roche Jr.

A Muncy hospital has been cited for failing to have a signed consent form in the record of a deceased patient whose eyes and skin were donated to an organ procurement agency. The deficiency was noted in a May 21 licensure inspection report on UPMC Muncy, a 20 in-patient bed facility which describes itself as "a full service critical access" hospital.
According to the report, which was recently posted by the state Health Department, the unidentified patient died on Sept. 20, 2020 and was brought to the operating room for harvesting of eye, skin and musculoskeletal tissue. "No consent for donation," state surveyors reported after reviewing the patient's file.
As part of its plan of correction the Lycoming County hospital indicated it had been in touch with staff of the Gift of Life, the local organ procurement agency, to ensure that consent forms were included in future patient records.
The lack of a consent form was one of several citations included in the May 21 report. A review of hospital records showed that two members of the hospital board were sitting on the patient safety committee, a violation of a state law, the Medical Care Availability and Reduction of Error Act.
According to the plan of correction, one of the board members was removed from the committee.
Other items cited in the state report include open medication containers without dates indicating when they were opened and outdated supplies that had not been discarded.
The report also cites the hospital for failing to have an operating CAT scan service of Jan. 4 and Jan. 5 of this year. Four patients requiring those services had to be shuttled to another facility.
A UPMC spokeswoman said the facility filed a plan of correction that was accepted by the state.
"UPMC Muncy is cooperating with state officials and implemented a corrective action plan to address the issues in the complaint. The plan has been reviewed and accepted by the Department of Health," UPMC spokeswoman Jackie Flanagan wrote in an email response to questions.
She did not respond to questions about the missing organ donor consent form.
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Multiple Violations at Philly Pediatric Hospital

By Walter F. Roche Jr.

Nine neonatal patients at a major Philadelphia pediatric hospital were given contaminated baby formula, according to a report from the state Health Department.
The formulae, some contaminated with gram positive bacillus was administered to the patients at the 188-bed Saint Christopher's Hospital for Children, but were not immediately reported to the state Health Department and a patient safety authority as required by law.
The baby formula deficiency was one of several violations turned up in a state Health Department inspection to certify the facility for continued eligibility in the federally funded Medicaid program.
An examination of hospital records showed facility officials concluded a single employee was responsible for the contamination. The report does not indicate whether the errors had any adverse impact on the nine patients.
"Do not allow employee to make formula. Put her back with someone for retraining," the hospital memo stated.
In another memo supervisors said the employee would be given a competency test. She will be put in with someone who will monitor, the memo stated.
"We thought these positive culture results were the result of poor technique," state health surveyors were told.
"Employee 42 was told to remediate the formula room technician," the report states. The employee subsequently resigned, the report states.
In addition to the contaminated formula, state surveyors learned that the baby formula was not being sterilized after preparation.
The records showed Saint Christopher "did not have a registered professional nurse or dietitian in charge of the facility's formula formulation," the 17-page report states.
A site inspection of the facility showed there were undated bottles of formula in a refrigerator and a patient in isolation was not being properly monitored.
A room occupied by a Covid-19 patient did not have a system in place to ensure negative pressure to prevent contamination from the room, the report stated.
"The facility failed to ensure a safe and sanitary environment was maintained throughout the operating suite," the report states citing the presence of an uncovered receptacle to empty bedpans and urinals next to a hand washing unit.
The hospital filed an acceptable plan of correction for only one of the citations. Hospital officials did not respond to requests for comment.
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Geisinger Patient Dies After Fall at Clinic

By Walter F. Roche Jr.

A major hospital failed to perform a physician prescribed test and sent the patient home. Three days later that patient was dead. A cause of death was not disclosed.
A state Health Department report on the May 2020 incident at the 550-bed Geisinger Medical Center states that unnamed patient first went to a Geisinger outpatient facility but fell backwards with the head striking a stool. The fall occurred while the patient was attempting to get on an examination table.
A physician at the outpatient center prescribed a CT (computed tomography)scan and referred the patient to the Geisinger Medical Center, the report states.
The patient went by private car to the Danville-based hospital but the CT scan order was never transmitted to the hospital, health department surveyors reported.
The facility "failed to facilitate a safe patient hand off," the report states, adding that "there was no provider to provider communication report."
According to the surveyors the patient complained of back and shoulder pain after arriving at the Geisinger Medical Center emergency department.
"There was no documentation the outpatient provider notified the Emergency Department," the report continued, adding that the patient was then discharged to home.
The facility "failed to ensure a patient transferred from the hospital's outpatient clinic to the emergency department for additional services recommended by the outpatient provider,"according to the report.
According to the state report a second more recent case with a communications lapse was discovered during the May visit to the hospital.
In that April 1 case a patient with high blood pressure and chest pains was referred to the main hospital by the clinic but the clinic did not inform the hospital or Geisinger Placement Services, which coordinates care between Geisinger facilities.
The hospital filed a plan of correction in which it said staff were being re-educated on the requirement that referrals be reported to the referred party and to Geisinger Placement Services.
Geisinger officials did not respond to requests for comment.
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Danville State Hospital In Repeat Violations

This story was updated 6/17/21

By Walter F. Roche Jr.

A state run facility for the mentally ill has been cited for the second time for failing to eliminate over a dozens items that could be used by a suicidal patient to end his or her life.
The violation was uncovered recently by state Health Department surveyors who were inspecting the 180-bed Danville State Hospital for re-certification in the federal Medicare and Medicaid programs.
The hospital "must be maintained to ensure the safety of the patients," the report states, adding that the findings indicate "systemic non-compliance."
The survey found that on multiple electrical beds wires longer than six feet were accessible and could be used by patients in a suicide attempt. The six foot cords were found in four of six behavioral units.
"This is a repeat violation," the report states.
In fact the same violations were cited in a April 12, 2018 inspection of the Montour County facility.
Noting that hangling and strangulation account for 75 per cent of all deaths in psychiatric facilities, the report states that the so-called ligature risk assessments were supposed to be conducted every month.
While some hospital records indicated those monthly assessments were performed, hospital staff acknowledged to the state surveyors that they were not. The hospital employees blamed the lapse on the pandemic.
Nonetheless the hospital records indicated the reports were submitted and reviewed. An employee "confirmed the documentation was incorrect," the report added.
Hospital employees also were unable to produce action plans implemented in response to the 2018 inspection.
"No documentation was provided," the report states.
The hospital provided a plan of correction in which it promised to make the electrical cords inaccessible and to educate staff on the necessity of eliminating ligature risks.
"The facility will ensure all current hospital bed cords have been secured with ties," the plan of correction states.
Spokeswoman Erin James said the plan of correction has been implemented. She also said there have been no suicides or attempted suicides at Danville in over a decade. She said there are 156 patients at the facility currently.
Still other violations were cited in the food preparation area of the facility. Dozens of logs maintained to document cleaning tasks were performed were left blank.
James said the cleaning was done but hospital employees failed to fill out the logs.
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Pocono Hospital Cited For ER Lapses

By Walter F. Roche Jr.

For the second time in a matter of months, a Pocono hospital has been cited by state health surveyors this time for understaffing in the emergency room.
A report just made public by the state Health Department concludes that, the Lehigh Valley Hospital-Pocono "failed to provide adequate staffing in the emergency area."
Citing hospital staffing reports, the state surveyor found that the actual staffing in the emergency area did not even meet the hospital's own standards.
According to the report several patients who showed up for emergency care left without even being seen.
On one day in early April nine patients gave up and left without being seen. Those patients included one who had expressed suicidal ideations.
In early February 15 patients left the emergency room in a single day without being seen, according to the report. In January 4.1 percent of the ER patients left without being seen. In February and March 3.7 percent and 3.5 percent of the ER patients left without being seen.
The hospital filed a plan of correction in which it said eight agency registered nurses had been added for the peak shifts. And two more had been requested.
The report marks the second time in recent months that the 249-bed East Stroudsburg facility has been cited for lapses in care.
In a previous report the state surveyors found that a 79-year-old patient in critical condition was kept waiting for five hours before being transferred to a higher level of care and placed on a monitor as ordered by a physician.
Hospital officials did not respond to questions about the latest report.
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Hershey Transplant Program Cited

By Walter F. Roche Jr.

The Milton S. Hershey Medical Center has been cited for failing to promptly notify transplant officials that transplant candidates had been removed from their waiting list.
In a recent report state Health Department found that in four cases the facility failed to notify the Organ Procurement and Transplantation Network within 24 hours that a candidate had been dropped from the program waiting list. In one case there was a two week delay.
Candidates can be removed from the list for several reasons including death and procurement of an organ from another source.
The cases cited by the state range from April to October of 2020.
For instance when a patient was dropped from the wait list on Sept. 3, 2020, OPTN was not notified until Sept. 8.
In another case, the patient was dropped from the waiting list on April 9, 2020 but OPTN was not notified until April 24, 2020.
In its plan of correction submitted to the state, the medical center said it revised procedures to follow when a transplant candidate dies. The plan also provided for staff re-education on the notification requirement.
The report does not specify what organs the four patients were waiting for but Hershey has transplant programs for adult heart, kidney and liver and pediatric kidney.
In another action related to transplant programs, the state Health Department recertified adult heart, kidney, pancreas and liver transplant programs at Allegheny General Hospital.
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PA Breakthrough Covid Cases Disappear

By Walter F. Roche Jr.

In mid-April, Pennsylvania health officials disclosed there had been 332 breakthrough cases, cases in which vaccinated patients contracted Covid-19 more than two weeks after a final injection.
This week, more than a month and a half later, they reported only 294 breakthroughs. Similar figures were reported at the federal level, 5.800 breakthrough cases in April and 2,737 currently.
The discrepancies have a simple explanation. The U.S. Centers for Disease Control and Prevention changed the definition of a breakthrough case. The new definition, adopted retroactively on May 1, counts only those breakthrough cases resulting in hospitalization or death.
Pennsylvania health officials say the change allows health officials to focus on "the cases of highest clinical and public health significance."
Mark O'Neill, a state health department spokesman, said data collected thus far shows those who test positive for Covid-19 after being vaccinated "are far less likely to show severe symptoms or require hospitalization and that the amount of virus they shed will be much lower."
Some health experts disagree and have charged that the effect of the new policy is to put on a blindfold.
Robert H. Shmerling MD of Harvard Health Publishing called the shift "disappointing."
Advantages of collecting data on all breakthrough cases, he wrote, include the possibilities determining that one of the appoved vaccines is more susceptible to breakthroughs than the others.
He speculated that another reason for the CDC change might be the concern that if the public perception was that the vaccines were not working, people would be discouraged from getting vaccinated.
Shmerling also noted more detailed data on all breakthroughs might reveal whether certain age groups or genders are more susceptible to breakthroughs.
"It would seem wise to pay more, not less attention" to breakthrough data, Shmerling concluded.
Supporters of the CDC change point out that breakthroughs were not unexpected since the two most effective of the vaccines are only about 95 per cent effective.
O'Neill, the state spokesman said that even the revised figures may overstate the number of significant breakthrough cases.
"It would clearly be inaccurate to state that all of the 257 hospitalizations and 37 deaths were related to COVID-19," he wrote in an email response to questions.
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Excesive Restraints For Autistic Patient

By Walter F. Roche Jr.

One of the facilties in a six hospital system has been cited for keeping an autistic patient in restraints for some 32 days between late last year and early this year.
In a 22-page report made public last week, state Health Department investigators concluded the Penn Highlands Hospital at Huntingdon failed to limit admissions to its behavioral unit to patients it was capable of providing needed care.
The patient had a history of autism spectrum, intellectual disability and bipolar disorder, according to the report.
A review of records at the 71-bed facility showed the unnamed patient was kept in restraints for 32 days after displaying violent, self destructive behavior.
The facility "failed to ensure needed communication assistance was provided" to the patient who spoke little and gave one word answers.
Though the patient had in the past made some progress with visual icons, there was no record that they were utilized in dealing with the patient.
The facility failed "to ensure a patient received dignified care at all times," according to the report.
The report states that there was no documentation that the patient was re-assessed face-to-face every eight hours while in restraints.
"When a hospital provides psychiatric services, it shall be provided in a manner sufficient to meet the patient's needs," the report states, adding that a facility should limit admissions to those it is capable of providing needed care for.
Toileting problems with the unnamed patient were reported and in one instance the patient got off the toilet and charged at the staff.
"There was no documentation the patient had been offered toileting. There was no documentation of incontinence," the report states.
"We do not have the staff," one hospital employee told the state surveyors, adding that "Multiple people are needed for the care of this patient and one person can't handle this patient."
The facility also failed to develop an individualized treatment plan for the patient and failed to ensure that physician consults for possible surgery were implemented. In a plan of correction filed with the state the hospital said it would re-educate staff on the use of restraints, admission requirements and the rights and responsibilities of patients. Hospital officials did not respond to a series of questions about the report.
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M-Care Violations at Surgical Hospital

By Walter F. Roche Jr.

An outpatient surgical center co-owned by some of the most prestigous medical facilities in the Philadelphia region has been cited for failing to report eight serious events in which patients had to be transferred to another facility.
The Physicians Care Surgical Hospital in Royersford had to transfer the patients when they experienced a variety of conditions ranging from hypoxia to atrial fibrillation. The transfers, which the state considers "serious events" were not reported to the state Health Department or the Patient Safety Authority.
The 30,000 square foot facility, located in western Montgomery County, is co-owned by the Rothman Institute, Main Line Health, Jefferson Health and NueHealth, an operator of physician owned health facilities.
The report, which was recently made public, was based on a full licensure survey conducted by the state Health Department.
The report states that the failure to report the eight patient transfers violated the state Medical Care Availability and Reduction of Error Act, known as M-Care.
"Serious events must be reported within 24 hours of their discovery," the report states, adding that the facility should transfer any patient who's presenting medical conitions the facility is not equipped to handle.
Three of the patients had to be transferred after EKG changes. Another was transerred due to "malignant hypertension."
Other violations of state requirements included the failure to establish a separate patient safety committee.
In fact the hospital was using one committee to fulfill state requirements for separate panels, including an infection control committee.
Still other violations including sanitation problems in the food preparation area, dusty areas in some of the 12 patient rooms and an operating room.
When a state investigator asked about the dirty cover on a trash can in an operating room, an employee offered a quick explanation.
"That's probably blood. We did a joint replacement in here this morning and the blood just sprays."
The facility did not file an acceptable plan of correction with the state and hospital officials did not respond to questions.
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