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
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