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
Tuesday, March 22, 2022
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
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