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.
Contact: wfrochejr999@gmail.com
Tuesday, June 29, 2021
Tuesday, June 22, 2021
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.
Contact: wfrochejr999@gmail.com
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.
Contact: wfrochejr999@gmail.com
Wednesday, June 16, 2021
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.
Contact: wfrochejr999@gmail.com
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.
Contact: wfrochejr999@gmail.com
Tuesday, June 8, 2021
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.
Contact: wfrochejr999@gmail.com
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.
Contact: wfrochejr999@gmail.com
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.
Contact: wfrochejr999@gmail.com
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.
Contact: wfrochejr999@gmail.com
Thursday, June 3, 2021
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.
Contact: wfrochejr999@gmail.com
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.
Contact: wfrochejr999@gmail.com
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