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.
Contact: wfrochejr999@gmail.com
Monday, November 29, 2021
Monday, November 8, 2021
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.
Contact: wfrochejr999@gmail.com
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.
Contact: wfrochejr999@gmail.com
Tuesday, November 2, 2021
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.
Contact: wfrochejr999@gmail.com
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.
Contact: wfrochejr999@gmail.com
Monday, November 1, 2021
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.
Contact: wfrochejr999@gmail.com
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.
Contact: wfrochejr999@gmail.com
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