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
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