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
Friday, August 27, 2021
Wednesday, August 18, 2021
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
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
Sunday, August 15, 2021
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
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
Thursday, August 12, 2021
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
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
Tuesday, August 10, 2021
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.
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.
Monday, August 9, 2021
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
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
Friday, August 6, 2021
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
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
Monday, August 2, 2021
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
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
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