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.
Contact: wfrochejr999@gmail.com
Thursday, December 23, 2021
Tuesday, December 21, 2021
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.
Contact: wfrochejr999@gmail.com
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.
Contact: wfrochejr999@gmail.com
Monday, December 13, 2021
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.
Contact: wfrochejr999@gmail.com
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.
Contact: wfrochejr999@gmail.com
Tuesday, December 7, 2021
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.
Contact wfrochejr999@gmail.com
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.
Contact wfrochejr999@gmail.com
Monday, December 6, 2021
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.
Contact: wfrochejr999@gmail.com
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.
Contact: wfrochejr999@gmail.com
Wednesday, December 1, 2021
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.
Contact: wfrochejr999@gmail.com
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.
Contact: wfrochejr999@gmail.com
Subscribe to:
Posts (Atom)