By Walter F. Roche Jr.
Security personnel at a major Philadelphia hospital dragged an emergency room patient from her seat, deliberately causing the patient to make "forcible contact" of her head and body to a metal detector before ejecting the her from the facility.
That incident was one of two cited by state health officials in a highly critical 60-page report on the Hospital of the Unversity of Pennsylvania (HUP)recently made public.
The incidents, which one HUP employee dismissed as an "unfortunate isolated incident," resulted in the four employees being placed on administrative leave and later terminated. The incidents occurred at the Emergency Room of a remote HUP facility on Cedar Avenue.
HUP officials did not respond to a series of questions on the report, but they did file a Plan of Correction with the state.
According to the April 27 report the first incident occurred at 3:02 a.m.on April 3 when an unnamed female patient, who had completed the registration process, left in "a state of verbal distress," but was grabbed by an employee "from the rear of the collar" and then, joined by 2 other employees, ejected her from the emergency department.
The patient "appeared to be emotionally and physically distressed and resistant to the physical handling and removal from the emergency department," the report states, citing videotaped recordings of the incident.
The report states that three of the employees "purposely made forcible contact of the head and body of the patient with a metal detector."
Citing the "seriousnes of the hospital's failure to comply with state law and regulations, the report cites (HUP)for failing to assess and treat the patient.
The second patient at the same HUP emergency facility had become verbally abusive and threatening and was asked to leave.
After the patient was asked to leave for a second time the report states that patient laid down on the sidewalk and later eloped.
The report concludes that HUP violated the the federal Emergency Medical Treatment and Labor Act and "failed to provide services in a safe environment."
The hospital's plan of correction calls for close monitoring of patients seeking care in the emergency department, staff re-education and a series of audits and reporting the incidents to local law enforcement officials.
Contact: wfrochejr999@gmail.com
Tuesday, June 21, 2022
Monday, June 13, 2022
Fire In Hospital OR Injures Patient
By Walter F. Roche Jr.
A 60-year old patient suffered facial burns and had to be transferred to a tertiary care burn center after a fire broke out in an operating room in a Pocono Mountain health facility.
In a six-page report recently made public by the state Health Department the fire was attributed to the fact that one of the staffers assigned to the operating rooom had not been trained on proper procedures to avoid a fire when skin preparations with alcohol, oxygen and cauterizing equipment are in use.
Saint Luke's Monroe Campus Hospital had been given a waiver to allow for oxygen use in cauterizations but the conditions of that waiver were not met, the report states.
"It was determined that the facility failed to ensure staff working in the operating room were educated in the use of surgical skin preparations that contain combustible agents," the April 21 report states.
In fact a second person in the operating room on April 15 also was untrained but apparently was not directly involved in the incident.
The report notes that the patient was oxygen dependent and required a face mask placing him in the highest risk category for fire.
The state investigation determined that it was the cauterizing equipment that caused the fire which spread to a drape.
"The drape was taken off the patient's face and the fire was extinguished, the report continues.
The patient was then intubated to assess any airway damage, but no injury was found. Injury, however, was detected to the nose and eyelids and further testing was needed to determine any ocular injury..
The recommendation called for transfer to a tertiary care burn center. The report does notindicate the patient's ultimate outcome
A review of hospital records showed no evidence that two staffers, including the one imvolved in the fire. had been trained in the use of surgical skin preparations thar include combustible agents.
In its plan of correction, which was accepted by state health officials said staff would be re-educated on the requirements and safety procedures to be followed in the event of fire in an operating room.
Hospital officials did not respond to a series of questions including the status of the injured patient.
Contact: wfrochejr999@gmail.com
A 60-year old patient suffered facial burns and had to be transferred to a tertiary care burn center after a fire broke out in an operating room in a Pocono Mountain health facility.
In a six-page report recently made public by the state Health Department the fire was attributed to the fact that one of the staffers assigned to the operating rooom had not been trained on proper procedures to avoid a fire when skin preparations with alcohol, oxygen and cauterizing equipment are in use.
Saint Luke's Monroe Campus Hospital had been given a waiver to allow for oxygen use in cauterizations but the conditions of that waiver were not met, the report states.
"It was determined that the facility failed to ensure staff working in the operating room were educated in the use of surgical skin preparations that contain combustible agents," the April 21 report states.
In fact a second person in the operating room on April 15 also was untrained but apparently was not directly involved in the incident.
The report notes that the patient was oxygen dependent and required a face mask placing him in the highest risk category for fire.
The state investigation determined that it was the cauterizing equipment that caused the fire which spread to a drape.
"The drape was taken off the patient's face and the fire was extinguished, the report continues.
The patient was then intubated to assess any airway damage, but no injury was found. Injury, however, was detected to the nose and eyelids and further testing was needed to determine any ocular injury..
The recommendation called for transfer to a tertiary care burn center. The report does notindicate the patient's ultimate outcome
A review of hospital records showed no evidence that two staffers, including the one imvolved in the fire. had been trained in the use of surgical skin preparations thar include combustible agents.
In its plan of correction, which was accepted by state health officials said staff would be re-educated on the requirements and safety procedures to be followed in the event of fire in an operating room.
Hospital officials did not respond to a series of questions including the status of the injured patient.
Contact: wfrochejr999@gmail.com
Wednesday, June 8, 2022
Multiple Errors in Vet Benefit Program
By Walter F. Roche Jr.
Multiple errors were uncovered in a multimillion veterans program, according to a 50-page audit report from the Inspector General for the U.S. Veterans Administration.
The report made public today concluded that despite the continuing discovery of multiple errors VA officials inexlicably suspended contract provisions under which they could have imposed fiscal penalties on the contractors due to excess errors.
The program, which was run by three primary contractors, performed exams on veterans seeking benefits for service related medical conditions.
The program was deficient, the report states, because it did hold contractors accountable for correcting errors and improving exam accuracy. Two of the three contractors had political connections raising charges from competitors of favoritism. Logistics Health a Wisconsin firm, hired former Associate Secretary of Defense William Winkenwerder as its president and former Secretary of Health Tommy Thompson a board chairman. QTC Management was established by Anthony Principi, a two time Secretary of Veterans Affairs. A third contractor, Veterans Evaluation Services, had no ostensible political connections.
According to the report, all three contractors failed to meet a 92 percent accuracy rate in the reports provided to the VA.
The auditors did not provide a breakdown of how much each of the three vendors were paid but noted the agency spent $6.8 billion on those exams since 2017. The audit states that VA officials concluded that language in the contracts prevented them from imposing financial penalties.c Both Logistics Health and QTC have since been sold.
Other findings included the fact that when the contractors did discover errors, they failed to report them to the VA.
"It is vital for the VBA (Veterans Benefit Administration) to make improvements to the governance of the contract exam program and accountability for it," the report states.
In a response, VA officials did not dispute the major findings but stated that improvements made since the audit period had addressed them.
Contact: wfrochejr999@gmail.com
Multiple errors were uncovered in a multimillion veterans program, according to a 50-page audit report from the Inspector General for the U.S. Veterans Administration.
The report made public today concluded that despite the continuing discovery of multiple errors VA officials inexlicably suspended contract provisions under which they could have imposed fiscal penalties on the contractors due to excess errors.
The program, which was run by three primary contractors, performed exams on veterans seeking benefits for service related medical conditions.
The program was deficient, the report states, because it did hold contractors accountable for correcting errors and improving exam accuracy. Two of the three contractors had political connections raising charges from competitors of favoritism. Logistics Health a Wisconsin firm, hired former Associate Secretary of Defense William Winkenwerder as its president and former Secretary of Health Tommy Thompson a board chairman. QTC Management was established by Anthony Principi, a two time Secretary of Veterans Affairs. A third contractor, Veterans Evaluation Services, had no ostensible political connections.
According to the report, all three contractors failed to meet a 92 percent accuracy rate in the reports provided to the VA.
The auditors did not provide a breakdown of how much each of the three vendors were paid but noted the agency spent $6.8 billion on those exams since 2017. The audit states that VA officials concluded that language in the contracts prevented them from imposing financial penalties.c Both Logistics Health and QTC have since been sold.
Other findings included the fact that when the contractors did discover errors, they failed to report them to the VA.
"It is vital for the VBA (Veterans Benefit Administration) to make improvements to the governance of the contract exam program and accountability for it," the report states.
In a response, VA officials did not dispute the major findings but stated that improvements made since the audit period had addressed them.
Contact: wfrochejr999@gmail.com
Tuesday, May 17, 2022
State "Edits" Hospital Incident Reports
By Walter F. Roche Jr.
In increasing numbers the Pennsylvania Health Department has been publicly posting inspection reports on hospitals that leave the public only to guess what prompted the report in the first place.
When asked about the practice, a department spokeswoman said the agency routinely edits hospital incident reports to bring them into compliance with federal requirements.
"The Department of Health continuously evaluates best practices for sharing survey findings on the website to be consistent with the Centers for Medicaid and Medicare Services. The language you mention was a part of that effort," Maggi Barton, the agency spokeswoman responded when asked whether information had been deleted from a report on the Geisinger Wyoming Medical Center.
The report dated Feb. 17 states as follows: "It was determined that the allegation was substantiated. The hospital identified the violation on its own and took effective corrective action prior to the investigation," the report states.
Identical language was contained in a March 24 report on the Geisinger Community Medical Center.
"The hospital identified the violation and took effective corrective action on its own," the report states.
A March 15 report on the Fulton County Medical Center states simply that the facility was found to be out of compliance with federal standards for the Medicare and Medicaid programs.
A March 16 report on the Moses Taylor Hosptal in Scranton states,"It was determined that the allegation was substantiated. The hospital identified the violation on its own and took effective corrective action prior to the investigation," the report states.
Contact: wfrochejr999@gmail.com
In increasing numbers the Pennsylvania Health Department has been publicly posting inspection reports on hospitals that leave the public only to guess what prompted the report in the first place.
When asked about the practice, a department spokeswoman said the agency routinely edits hospital incident reports to bring them into compliance with federal requirements.
"The Department of Health continuously evaluates best practices for sharing survey findings on the website to be consistent with the Centers for Medicaid and Medicare Services. The language you mention was a part of that effort," Maggi Barton, the agency spokeswoman responded when asked whether information had been deleted from a report on the Geisinger Wyoming Medical Center.
The report dated Feb. 17 states as follows: "It was determined that the allegation was substantiated. The hospital identified the violation on its own and took effective corrective action prior to the investigation," the report states.
Identical language was contained in a March 24 report on the Geisinger Community Medical Center.
"The hospital identified the violation and took effective corrective action on its own," the report states.
A March 15 report on the Fulton County Medical Center states simply that the facility was found to be out of compliance with federal standards for the Medicare and Medicaid programs.
A March 16 report on the Moses Taylor Hosptal in Scranton states,"It was determined that the allegation was substantiated. The hospital identified the violation on its own and took effective corrective action prior to the investigation," the report states.
Contact: wfrochejr999@gmail.com
Saturday, May 14, 2022
Patient at City Facility Sexually Abused
Note: This story was updated on May 18 with comment from the city Health Department.
By Walter F. Roche Jr.
A cognitively impaired longtime resident of a Philadelphia owned nursing home was sexually abused by a facility employee who was caught naked with the victim in a closed section of the 402-bed facility.
The discovery of the abuse was detailed in a 14-page report recently made public by the state Health Department. When confronted with the incident the employee denied engaging in inappropriate behavior but stated to one supervisor,"I don't know what to say, you need to keep this between us."
According to the report, the relationship came to light on March 11 when an employee was making the rounds and checked Room 560 after hearing some noise in the unoccupied room. When he opened the door he observed an employee, a general mechanic, "completely naked with his clothes in a pile by the window."
The security employee did not see anyone else in the room, but a later review of surveillance camera footages showed the mechanic and the cognitavely impaired patient exiting the same room about two minutes later.
The mechanic eventually told investigators the relationship had become sexual only recently and amounted to "kisses and maybe some fondling." He denied having sex with the patient.
The patient told supervisors they had sex "a few times, total."
She began crying at one point in the interview and stated that she did not want the mechanic to be mad at her and think that she had reported the relationship.
The administrator of the facility, state surveyors reported, kept insisting that the relationship was "consensual despite the fact thay the patient had been diagnosed with cognitive impairment."
According to the report the mechanic was terminated on March 14, just three days after he was observed naked.
The director of nursing said she did not make the staff aware of what was going on because the matter was under investigation internally and by the police.
As for the patient's cognitive impairment, the report cites recent testing and previous diagnoses finding that she did not have a sound mind.
In a plan of correction filed with the state, nursing home administrators said they issued a formal poliicy statement barring sexual relations between staff and patients.
The plan also calls for staff re-education on sexual abuse and the responsibility to report any suspected abuse.
"All residents will be interviewed regarding sexual interactions," the report states, adding that they will be specifically asked about any sexual interactions between residents and staff.
Health Department officials noted that a subsequent inspection by state surveyors showed that all of the cited deficiencies had been corrected.
Contact: wfrochejr999@gmail.com
A cognitively impaired longtime resident of a Philadelphia owned nursing home was sexually abused by a facility employee who was caught naked with the victim in a closed section of the 402-bed facility.
The discovery of the abuse was detailed in a 14-page report recently made public by the state Health Department. When confronted with the incident the employee denied engaging in inappropriate behavior but stated to one supervisor,"I don't know what to say, you need to keep this between us."
According to the report, the relationship came to light on March 11 when an employee was making the rounds and checked Room 560 after hearing some noise in the unoccupied room. When he opened the door he observed an employee, a general mechanic, "completely naked with his clothes in a pile by the window."
The security employee did not see anyone else in the room, but a later review of surveillance camera footages showed the mechanic and the cognitavely impaired patient exiting the same room about two minutes later.
The mechanic eventually told investigators the relationship had become sexual only recently and amounted to "kisses and maybe some fondling." He denied having sex with the patient.
The patient told supervisors they had sex "a few times, total."
She began crying at one point in the interview and stated that she did not want the mechanic to be mad at her and think that she had reported the relationship.
The administrator of the facility, state surveyors reported, kept insisting that the relationship was "consensual despite the fact thay the patient had been diagnosed with cognitive impairment."
According to the report the mechanic was terminated on March 14, just three days after he was observed naked.
The director of nursing said she did not make the staff aware of what was going on because the matter was under investigation internally and by the police.
As for the patient's cognitive impairment, the report cites recent testing and previous diagnoses finding that she did not have a sound mind.
In a plan of correction filed with the state, nursing home administrators said they issued a formal poliicy statement barring sexual relations between staff and patients.
The plan also calls for staff re-education on sexual abuse and the responsibility to report any suspected abuse.
"All residents will be interviewed regarding sexual interactions," the report states, adding that they will be specifically asked about any sexual interactions between residents and staff.
Health Department officials noted that a subsequent inspection by state surveyors showed that all of the cited deficiencies had been corrected.
Contact: wfrochejr999@gmail.com
Tuesday, May 3, 2022
VA RN Failed to Assess Suicidal Veteran
By Walter F. Roche Jr.
An unnamed nurse practitioner at a Veterans Administration facility in Pittsburgh failed to perform a risk assessment on a veteran with a history of suicide attempts and who, subsequently, did kill himself.
That finding was just one of a series of failures by the healthcare worker cited in a 38-page report from the VA Inspector General.
The 78-year old veteran was just one of eight patients with suicidal ideations, who were not given suicide risk assessments by the nurse, the report states.
"For unclear reasons the (nurse) BHNP failed to document suicide risk assessments," the report states, adding that if the assessments had been performed it might have resulted in different interventions.
Other deficiencies by the nurse included failing to get proper informed consent from patients being treated with anti-psychotic medications and failure to inform patients of possible side effects.
Very little information on the the patient who committed suicide was provided except the fact that he had a prior history of suicide attempts and that he had been charged with killing "a significant other."
Contact: wfrochejr999@gmail.com
An unnamed nurse practitioner at a Veterans Administration facility in Pittsburgh failed to perform a risk assessment on a veteran with a history of suicide attempts and who, subsequently, did kill himself.
That finding was just one of a series of failures by the healthcare worker cited in a 38-page report from the VA Inspector General.
The 78-year old veteran was just one of eight patients with suicidal ideations, who were not given suicide risk assessments by the nurse, the report states.
"For unclear reasons the (nurse) BHNP failed to document suicide risk assessments," the report states, adding that if the assessments had been performed it might have resulted in different interventions.
Other deficiencies by the nurse included failing to get proper informed consent from patients being treated with anti-psychotic medications and failure to inform patients of possible side effects.
Very little information on the the patient who committed suicide was provided except the fact that he had a prior history of suicide attempts and that he had been charged with killing "a significant other."
Contact: wfrochejr999@gmail.com
Thursday, April 14, 2022
"You Can't Kill Dead."..Hospital Employee
By Walter F. Roche Jr.
A patient at a Pittsburgh area hospital died after a doctor's orders were ignored and drug errors abounded, according to a state review.
The report on the PAM Specialty Hospital detailed a series of errors, many involving the failure to follow established safety procedures designed to ensure patients were getting the right medications.
In six of ten patient records reviewed by state surveyors errors or omissions in medication records were uncovered. In some cases the name of the person administering the medications was absent. In other cases, requiring two person verification, there was no verification.
In the case of the man who died at 3:07 am. on Aug 26 of last year, hospital records failed to disclose who initiated CPR or what drugs were administered.
When one hospital employee was asked about the missing details, he responded, "You can't kill dead."
The unnamed patient's records did show that he was "very lethargic..no longer responding with words.".. on the day he died.
His wife was informed of his changed condition, the records state, but his doctors apparently were not
When one of the employees was questioned about whether the patient was given lidocaine, he responded,"I don't remember using lidocaine..may have given a dose."
In response to the report PAM officials noted that the hospital and dozens of others had just been taken over by PAM and the new owners were still assessing the procedures needing improvement.
In its plan of correction PAM officials said employees were being re-educated on procedures to be followed when patients conditions changed. Audits were established to check patient records to ensure proper procedures were being followed.
Contact: wfrochejr999@gmail.com
A patient at a Pittsburgh area hospital died after a doctor's orders were ignored and drug errors abounded, according to a state review.
The report on the PAM Specialty Hospital detailed a series of errors, many involving the failure to follow established safety procedures designed to ensure patients were getting the right medications.
In six of ten patient records reviewed by state surveyors errors or omissions in medication records were uncovered. In some cases the name of the person administering the medications was absent. In other cases, requiring two person verification, there was no verification.
In the case of the man who died at 3:07 am. on Aug 26 of last year, hospital records failed to disclose who initiated CPR or what drugs were administered.
When one hospital employee was asked about the missing details, he responded, "You can't kill dead."
The unnamed patient's records did show that he was "very lethargic..no longer responding with words.".. on the day he died.
His wife was informed of his changed condition, the records state, but his doctors apparently were not
When one of the employees was questioned about whether the patient was given lidocaine, he responded,"I don't remember using lidocaine..may have given a dose."
In response to the report PAM officials noted that the hospital and dozens of others had just been taken over by PAM and the new owners were still assessing the procedures needing improvement.
In its plan of correction PAM officials said employees were being re-educated on procedures to be followed when patients conditions changed. Audits were established to check patient records to ensure proper procedures were being followed.
Contact: wfrochejr999@gmail.com
Wednesday, April 13, 2022
Lancaster Patient Blanks Out after RX Error
By Walter F. Roche Jr.
Seconds after being medicated a Lancaster General Hospital patient became unconscious but not before feeling "pain all over." His blood pressure plunged prompting immediate resuscitation efforts.
Rapid response was called due to the patient's altered mental state and hypotension. He was unresponsive to painful stimuli, the report adds.
After a few minutes the patient began to wake up and related that he could remember nothing except the incredible pain.
The Jan. 16 incident, as related in a state Health Department report, was triggered by an unnamed hospital employee who administered the drug, diazoxide, by injecting it into the patient's Peripherrally Inserted Central Catheter (PICC), speeding the drug directly into his circulatory system.
As the state report notes, diazoxide is a drug meant to be administered orally. In this patient's case that meant injecting the drug into his feeding tube.
The state surveyors, after examining hospital records, noted that the same hospital employee had previously administered the drug correctly.
"She knew it was oral, but somehow confused it on Jan. 16," another hospital employee told the surveyors.
"Based on review of facility documents, medical records and staff interview it was determined that medication orders were not administered in accordance with approved policies and procedures," the report states.
The state surveyors noted that the doctor's orders specified that the drug was to be administered orally.
In its plan of correction hospital officials said staff was re-educated on the importance of route administration. In addition adjustments to equipment were made to make it difficult to deliver drugs incorrectly.
Contact: wfrochejr999@gmail.com
Seconds after being medicated a Lancaster General Hospital patient became unconscious but not before feeling "pain all over." His blood pressure plunged prompting immediate resuscitation efforts.
Rapid response was called due to the patient's altered mental state and hypotension. He was unresponsive to painful stimuli, the report adds.
After a few minutes the patient began to wake up and related that he could remember nothing except the incredible pain.
The Jan. 16 incident, as related in a state Health Department report, was triggered by an unnamed hospital employee who administered the drug, diazoxide, by injecting it into the patient's Peripherrally Inserted Central Catheter (PICC), speeding the drug directly into his circulatory system.
As the state report notes, diazoxide is a drug meant to be administered orally. In this patient's case that meant injecting the drug into his feeding tube.
The state surveyors, after examining hospital records, noted that the same hospital employee had previously administered the drug correctly.
"She knew it was oral, but somehow confused it on Jan. 16," another hospital employee told the surveyors.
"Based on review of facility documents, medical records and staff interview it was determined that medication orders were not administered in accordance with approved policies and procedures," the report states.
The state surveyors noted that the doctor's orders specified that the drug was to be administered orally.
In its plan of correction hospital officials said staff was re-educated on the importance of route administration. In addition adjustments to equipment were made to make it difficult to deliver drugs incorrectly.
Contact: wfrochejr999@gmail.com
Tuesday, March 22, 2022
Patients Died While in Restraints
By Walter F. Roche Jr.
Two patients at a Pittsburgh hospital died while being held in restraints and the facility failed to properly and timely report the deaths to government agencies.
The incidents at UPMC Mercy were disclosed in an investigative report recently made public by the health agency.
The critical eight-page report states that in three of nine cases reviewed the patients were not being properly monitored.
UPMC officials did not respond to questions about the report. In one death case the hospital filed a report with a federal government agency indicating that the death occurred after the restraints were removed. Patient records, however showed the patient died while still in restraints.
The hospital filed a plan of correction in which they promised that staff involved with restraints would be re-educated on the proper use of restraints and the state and federal reporting requirements.
Contact: wfrochejr999@gmail.com
Two patients at a Pittsburgh hospital died while being held in restraints and the facility failed to properly and timely report the deaths to government agencies.
The incidents at UPMC Mercy were disclosed in an investigative report recently made public by the health agency.
The critical eight-page report states that in three of nine cases reviewed the patients were not being properly monitored.
UPMC officials did not respond to questions about the report. In one death case the hospital filed a report with a federal government agency indicating that the death occurred after the restraints were removed. Patient records, however showed the patient died while still in restraints.
The hospital filed a plan of correction in which they promised that staff involved with restraints would be re-educated on the proper use of restraints and the state and federal reporting requirements.
Contact: wfrochejr999@gmail.com
Monday, March 21, 2022
Missing Monitor Proves Deadly
By Walter F. Roche Jr.
The failure to attach a monitor to a critically ill patient ended with the death of the patient at a Philadelphia area hospital, according to a report from the state Health Department.
In a report on a complaint investigation at the Jefferson-Lansdale Hospital, state surveyors said the patient was found unresponsive and lifeless and without the cardiac monitor that had been ordered by a hospital physician hours earlier.
"The patient expired," the report states.
"Attempts at resuscitation were not succesful." In interviews hospital employees acknowledged the monitor was ordered, "It just was not implemented."
Due to the finding the state surveyors on Jan. 26 declared a state of "immediate jeopardy", forcing hospital officials to come up with an immediate written response.
The hospital came up with a plan to immediately notify responsible employees of the requirement to place monitors on patients immediately or within an hour of their arrival. The "immediate jeopardy" declaration was lifted at 7:12 p.m.
Hospital officials, however, did not file an acceptable plan of correction with the state Health Department and did not respond to a reporter's request for comments.
After reviewing hospital records, the inspectors concluded, "It was determined that a registered nurse failed to follow a physician's order to place a telemetry monitor for cardiac monitoring."
Contact:wfrochejr999@gmail.com
The failure to attach a monitor to a critically ill patient ended with the death of the patient at a Philadelphia area hospital, according to a report from the state Health Department.
In a report on a complaint investigation at the Jefferson-Lansdale Hospital, state surveyors said the patient was found unresponsive and lifeless and without the cardiac monitor that had been ordered by a hospital physician hours earlier.
"The patient expired," the report states.
"Attempts at resuscitation were not succesful." In interviews hospital employees acknowledged the monitor was ordered, "It just was not implemented."
Due to the finding the state surveyors on Jan. 26 declared a state of "immediate jeopardy", forcing hospital officials to come up with an immediate written response.
The hospital came up with a plan to immediately notify responsible employees of the requirement to place monitors on patients immediately or within an hour of their arrival. The "immediate jeopardy" declaration was lifted at 7:12 p.m.
Hospital officials, however, did not file an acceptable plan of correction with the state Health Department and did not respond to a reporter's request for comments.
After reviewing hospital records, the inspectors concluded, "It was determined that a registered nurse failed to follow a physician's order to place a telemetry monitor for cardiac monitoring."
Contact:wfrochejr999@gmail.com
Monday, March 7, 2022
Critical Patient's Care Delayed 82 Minutes
By Walter F. Roche Jr.
Emergency care for a "difficult" but critically ill patient was delayed one hour and 22 minutes at a Pittsburgh hospital ending in that patient's death.
Details of the December incident at the West Penn Hospital were recently made public in a 10-page report from the state Health Department. It concluded that the facility, part of the Allegheny Health Network, failed to protect the patient from neglect.
The report cites fellow hospital employees who concluded that the employees involved in the unnamed elderly patient's care were guilty of "gross misconduct."
The victim, who was recovering from severe burns over much of his body, had been a patient at the 317-bed hospital since July 31, but on Dec.20 his condition began to deteriorate with a sharp and sudden drop in his blood pressure.
Though the "acute change" was noted by one of the attending nurses, a doctor was not immediately notified, the report states.
An emergency reponse was finally triggered 82 minutes later when a second blood pressure drop triggered a Code Blue, but the patient remained pulseless and could not be revived. He was declared dead at 12:45 a.m. Dec. 11.
The report by state Health Department surveyors was apparently triggered by a complaint, but the source of the complaint was not disclosed.
Hospital officials failed to filed an acceptable plan of correction as required by state statutes and regulations and did not respond to requests for comment. The two employees blamed for the delayed care remained on the job, entrusted with the care of other patients, for 16 days while an internal investigation was conducted, according to the report.
At the end of that investigation, the report states, the two unnamed employees were terminated.
"The employees were union covered ... and were permitted to work in the same capacity during the investigation," the report states.
The surveyors' report indicates the delay in care was attributable, at least in part, to the fact that the patient was regarded by the staff as "difficult."
Citing the statements from another employee, the report states that "staff made a bad judgement and understood what staff failed to do but found the patient to be difficult." Relatives of the deceased patient did not respond to requests for comment.
The report states that in addition to suffering second and third degree burns over much of his body, the patient had also under gone an amputation during his extended treatment.
Contact: wfrochejr999@gmail.com
Emergency care for a "difficult" but critically ill patient was delayed one hour and 22 minutes at a Pittsburgh hospital ending in that patient's death.
Details of the December incident at the West Penn Hospital were recently made public in a 10-page report from the state Health Department. It concluded that the facility, part of the Allegheny Health Network, failed to protect the patient from neglect.
The report cites fellow hospital employees who concluded that the employees involved in the unnamed elderly patient's care were guilty of "gross misconduct."
The victim, who was recovering from severe burns over much of his body, had been a patient at the 317-bed hospital since July 31, but on Dec.20 his condition began to deteriorate with a sharp and sudden drop in his blood pressure.
Though the "acute change" was noted by one of the attending nurses, a doctor was not immediately notified, the report states.
An emergency reponse was finally triggered 82 minutes later when a second blood pressure drop triggered a Code Blue, but the patient remained pulseless and could not be revived. He was declared dead at 12:45 a.m. Dec. 11.
The report by state Health Department surveyors was apparently triggered by a complaint, but the source of the complaint was not disclosed.
Hospital officials failed to filed an acceptable plan of correction as required by state statutes and regulations and did not respond to requests for comment. The two employees blamed for the delayed care remained on the job, entrusted with the care of other patients, for 16 days while an internal investigation was conducted, according to the report.
At the end of that investigation, the report states, the two unnamed employees were terminated.
"The employees were union covered ... and were permitted to work in the same capacity during the investigation," the report states.
The surveyors' report indicates the delay in care was attributable, at least in part, to the fact that the patient was regarded by the staff as "difficult."
Citing the statements from another employee, the report states that "staff made a bad judgement and understood what staff failed to do but found the patient to be difficult." Relatives of the deceased patient did not respond to requests for comment.
The report states that in addition to suffering second and third degree burns over much of his body, the patient had also under gone an amputation during his extended treatment.
Contact: wfrochejr999@gmail.com
Tuesday, February 22, 2022
City Nursing Home Has Staffing Woes
By Walter F. Roche Jr.
A city-owned nursing home has been hit with two critical reports from state health surveyors who found the facility understaffed, dirty and with one patient out-of-control and injuring a fellow patient.
In two recent reports on the 402-bed Philadelphia Nursing Home, state Health Department inspectors found numerous deficiencies. The first report dated Dec. 9 specifically focused on staffing levels and found that on more than half the days reviewed the facility failed to maintain state mandated staffing levels.
While the state requires a facility to provide 2.7 hours of nursing care per patient per day the surveyors found that on 11 of 21 days reviewed the facility failed to meet that standard.
In the second report dated Jan. 10, surveyors concluded the facility "failed to maintain a clean and homelike environment for one of eight nursing units."
That second survey, which was conducted to determine whether the facility met federal Medicare and Medicaid standards, concluded that it didn't.
A clutter of trash was found next to one patient's bed and dried food was caked to a patient's wheelchair.
There was no care plan developed for three patients and proper incontinence care had not been provided to other patients. One of those patients told surveyors that when she pressed her call light for assistance, it was ignored.
The tracheotomy equipment for another patient was dirty and overdue for maintenance. Other issues included "a mice problem" which one surveyor witnessed first hand and failure to arrange a psychiatric review for an Alzheimer's patient.
Another patient with psychiatric issues threw a bedside table at another patient. That patient was referred for a psychiatric review on Oct. 19 but did not get it until Nov. 12.
James Garrow, a city Health Department spokesman, said that the facility was holding job fairs and working with several different agencies in an attempt to fill vacant nursing home positions.
He said that current levels were at 3.38 hours of nursing care per patient per day, well above the state's minimum standards.
In it's plan of correction, which was accepted by the state, the nursing home reported it had cleaned up the clutter of trash and cleaned the food stained wheekchair.
The plan calls for audits to ensure care plans were developed for all patients. The overall plan also calls for psychiatric consults to be completed immediately and improvements in incontinence care.
Contact: wfrochejr999@gmail.com
A city-owned nursing home has been hit with two critical reports from state health surveyors who found the facility understaffed, dirty and with one patient out-of-control and injuring a fellow patient.
In two recent reports on the 402-bed Philadelphia Nursing Home, state Health Department inspectors found numerous deficiencies. The first report dated Dec. 9 specifically focused on staffing levels and found that on more than half the days reviewed the facility failed to maintain state mandated staffing levels.
While the state requires a facility to provide 2.7 hours of nursing care per patient per day the surveyors found that on 11 of 21 days reviewed the facility failed to meet that standard.
In the second report dated Jan. 10, surveyors concluded the facility "failed to maintain a clean and homelike environment for one of eight nursing units."
That second survey, which was conducted to determine whether the facility met federal Medicare and Medicaid standards, concluded that it didn't.
A clutter of trash was found next to one patient's bed and dried food was caked to a patient's wheelchair.
There was no care plan developed for three patients and proper incontinence care had not been provided to other patients. One of those patients told surveyors that when she pressed her call light for assistance, it was ignored.
The tracheotomy equipment for another patient was dirty and overdue for maintenance. Other issues included "a mice problem" which one surveyor witnessed first hand and failure to arrange a psychiatric review for an Alzheimer's patient.
Another patient with psychiatric issues threw a bedside table at another patient. That patient was referred for a psychiatric review on Oct. 19 but did not get it until Nov. 12.
James Garrow, a city Health Department spokesman, said that the facility was holding job fairs and working with several different agencies in an attempt to fill vacant nursing home positions.
He said that current levels were at 3.38 hours of nursing care per patient per day, well above the state's minimum standards.
In it's plan of correction, which was accepted by the state, the nursing home reported it had cleaned up the clutter of trash and cleaned the food stained wheekchair.
The plan calls for audits to ensure care plans were developed for all patients. The overall plan also calls for psychiatric consults to be completed immediately and improvements in incontinence care.
Contact: wfrochejr999@gmail.com
Monday, February 7, 2022
Suicidal Patient Jumps to Death at Crozier
By Walter F. Roche Jr.
A shoeless psychiatric patient who had acknowledged having suicidal thoughts including plans to jump in front of an Amtrak train, was discharged unattended from an area hospital then climbed to an unsecured roof top access and jumped.
The fatal Nov. 16 incident at the Crozer Chester Medical Center was detailed in a recent 9-page report from the state Health Department.
"The facility failed to assist a patient at risk of suicide and failed to implement a plan to deal with withdrawal from alcohol," the report states.
The unnamed patient had been transported to the Upland hospital by an emergency medical team. He was rated as high risk for suicide after admitting to a plan to walk into a passing Amtrak train.
Asked if he had ever wished he was dead, the patient said, "Yes."
After being informed he was being discharged, the patient asked for shoes, but was told all of his belongings, including a wallet, had disappeared. When the hospital workers discovered they had no shoes that would fit him, he was given a second pair of socks.
Efforts to find a place in area shelter were unsuccesful.
When health department staffers reviewed the records they discovered a series of tests that should have been performed, but never were.
The facility failed to provide "a safe and detailed discharge," the report states.
The health department team also viewed surveillance videos shot during the discharge. "The last video shows the patient falling on the ground," the report states.
Crozer filed a plan of correction including new security measures to monitor the areas near the roof access point.
The plan also calls for the reassesment of patients for suicide risks and education of staffers, along with audits to ensure compliance.
The hospital did not respond to a series of questions about the incident and the state report.
Contact: wfrochejr999@gmail.com
A shoeless psychiatric patient who had acknowledged having suicidal thoughts including plans to jump in front of an Amtrak train, was discharged unattended from an area hospital then climbed to an unsecured roof top access and jumped.
The fatal Nov. 16 incident at the Crozer Chester Medical Center was detailed in a recent 9-page report from the state Health Department.
"The facility failed to assist a patient at risk of suicide and failed to implement a plan to deal with withdrawal from alcohol," the report states.
The unnamed patient had been transported to the Upland hospital by an emergency medical team. He was rated as high risk for suicide after admitting to a plan to walk into a passing Amtrak train.
Asked if he had ever wished he was dead, the patient said, "Yes."
After being informed he was being discharged, the patient asked for shoes, but was told all of his belongings, including a wallet, had disappeared. When the hospital workers discovered they had no shoes that would fit him, he was given a second pair of socks.
Efforts to find a place in area shelter were unsuccesful.
When health department staffers reviewed the records they discovered a series of tests that should have been performed, but never were.
The facility failed to provide "a safe and detailed discharge," the report states.
The health department team also viewed surveillance videos shot during the discharge. "The last video shows the patient falling on the ground," the report states.
Crozer filed a plan of correction including new security measures to monitor the areas near the roof access point.
The plan also calls for the reassesment of patients for suicide risks and education of staffers, along with audits to ensure compliance.
The hospital did not respond to a series of questions about the incident and the state report.
Contact: wfrochejr999@gmail.com
Monday, January 31, 2022
Patients at State Veterans Home Assaulted
By Walter F. Roche Jr.
Four patients at a state run nursing home for veterans were assaulted verbally or physically when officials of the Scranton facility failed to take action to restrain an assaultive fellow patient.
The incidents at the Gino Merli Veterans Center were detailed in a recent report from the state Health Department which noted that the attacks resulted in actual physical injury including a fractured finger and lacerations and contusions.
In one of the attacks the attacking patient punched another patient who was seated in his wheelchair, knocking him to the floor.
The patient was found lying on the floor, bleeding from a lip laceration and suffering from elbow lacerations.
The patient was later found to have a fractured pinky and required stitches for the mouth wounds.
Questioned about the attack, the victim said, "I was punched in the face by a man with white hair. My wheel chair fell over with me in it."
Surveyors from the health agency reviewed video tapes which confirmed the unprovoked attack.
Yet another victim was punched with a closed fist, the report states. Video of the incident showed the victim was punched five times.
The aggressor was sent to another facility for an evaluation, but was returned to the nursing home before the end of the day.
The final victim was subjected to expletive laced verbal abuse.
"The facility failed to ensure that four patients were free from physical and/or verbal abuse," according to the Dec. 3 report.
The nursing home's managers were also faulted for barring patients from having any visitors even after federal officials lifted a visitors' ban.
The facility filed a plan of correction in which officials said the assaultive patient was kept away from his victims. They also said the visitors ban was lifted.
Officials of the state agency which runs the veterans homes did not respond to questions about the report.
Contact: wfrochejr999@gmail.com
Four patients at a state run nursing home for veterans were assaulted verbally or physically when officials of the Scranton facility failed to take action to restrain an assaultive fellow patient.
The incidents at the Gino Merli Veterans Center were detailed in a recent report from the state Health Department which noted that the attacks resulted in actual physical injury including a fractured finger and lacerations and contusions.
In one of the attacks the attacking patient punched another patient who was seated in his wheelchair, knocking him to the floor.
The patient was found lying on the floor, bleeding from a lip laceration and suffering from elbow lacerations.
The patient was later found to have a fractured pinky and required stitches for the mouth wounds.
Questioned about the attack, the victim said, "I was punched in the face by a man with white hair. My wheel chair fell over with me in it."
Surveyors from the health agency reviewed video tapes which confirmed the unprovoked attack.
Yet another victim was punched with a closed fist, the report states. Video of the incident showed the victim was punched five times.
The aggressor was sent to another facility for an evaluation, but was returned to the nursing home before the end of the day.
The final victim was subjected to expletive laced verbal abuse.
"The facility failed to ensure that four patients were free from physical and/or verbal abuse," according to the Dec. 3 report.
The nursing home's managers were also faulted for barring patients from having any visitors even after federal officials lifted a visitors' ban.
The facility filed a plan of correction in which officials said the assaultive patient was kept away from his victims. They also said the visitors ban was lifted.
Officials of the state agency which runs the veterans homes did not respond to questions about the report.
Contact: wfrochejr999@gmail.com
Saturday, January 29, 2022
Monday, January 24, 2022
Meaness, Elopements Cited at Montgomery Facility
By Walter F. Roche Jr.
"There's a lot of meanness here," a patient at a Montgomery County nursing home told a surveyor from the Pennsylvania Health Department during a recent visit.
That encounter plus evidence of multiple violations of state requirements were detailed in a Nov. 10 report on the Meadow View Rehabilitation and Nursing Center in Lafayette Hill just feet away from the Philadelphia city line.
The inspectors found that the facility failed to properly investigate an incidents in which two disabled patients were able to walk out the door apparently unnoticed.
The patient who reported the "meanness," told the state employees he was barked at when he asked permission to leave his unit. He was advised not to ask again.
The surveyors found and observed several violations of infection control requirements in wards set up to treat patients who had contracted Covid-19 or had been in contact with someone who had the virus.
Employees were observed serving meals in the Covid-19 area without masks or protective equipment. Others were observed without the proper masks.
Employees told the inspectors that at one point in the midst of the pandemic there were no masks or protective gear available.
In other findings the records for a diabetic patient showed the physican overseeing care was not informed when blood/sugar levels skyrocketed.
In addition the facility had failed to set any goals or interventions for the patient.
"The patient complained his blood/sugar levels were not checked as required before an insulin injection," the report states.
Finally the report states that three smoking patients were not properly monitored and one patient's records were inaccurate.
Facilty officials did not respond to questions about the report. They did file a plan of correction with the state health agency. Under the plan officals of the 244-bed facility said housekeeping issues had been resolved and the nurse who yelled at a patient was instructed on the proper way to address a patient. The plan noted that the two patients who eloped were uninjured. Contact: wfrochejr999@gmail.com
"There's a lot of meanness here," a patient at a Montgomery County nursing home told a surveyor from the Pennsylvania Health Department during a recent visit.
That encounter plus evidence of multiple violations of state requirements were detailed in a Nov. 10 report on the Meadow View Rehabilitation and Nursing Center in Lafayette Hill just feet away from the Philadelphia city line.
The inspectors found that the facility failed to properly investigate an incidents in which two disabled patients were able to walk out the door apparently unnoticed.
The patient who reported the "meanness," told the state employees he was barked at when he asked permission to leave his unit. He was advised not to ask again.
The surveyors found and observed several violations of infection control requirements in wards set up to treat patients who had contracted Covid-19 or had been in contact with someone who had the virus.
Employees were observed serving meals in the Covid-19 area without masks or protective equipment. Others were observed without the proper masks.
Employees told the inspectors that at one point in the midst of the pandemic there were no masks or protective gear available.
In other findings the records for a diabetic patient showed the physican overseeing care was not informed when blood/sugar levels skyrocketed.
In addition the facility had failed to set any goals or interventions for the patient.
"The patient complained his blood/sugar levels were not checked as required before an insulin injection," the report states.
Finally the report states that three smoking patients were not properly monitored and one patient's records were inaccurate.
Facilty officials did not respond to questions about the report. They did file a plan of correction with the state health agency. Under the plan officals of the 244-bed facility said housekeeping issues had been resolved and the nurse who yelled at a patient was instructed on the proper way to address a patient. The plan noted that the two patients who eloped were uninjured. Contact: wfrochejr999@gmail.com
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