Temple Cited For Restraint Overuse

By Walter F. Roche Jr.

The Temple University Hospital placed patients in the most restrictive of restraints without proper justification, according to an inspection report from the Pennsylvania Health Department.
In a 40-page report just recently made public, surveyors from the state health agency found that staffers at Temple's Episcopal campus "failed to ensure that alternatives to restraints were utilized and proven to be ineffective prior to the application of restraints."
Instead, when state inspectors visited the 198-bed behavioral health facility late last year, they found several patients had been placed in four point restraints, the most restrictive available, without considering less restrictive alternatives.
In addition the report states staffers at the facility failed to remove those restraints in a timely manner and also failed to monitor patients while they were in those restraints.
Asked to comment on the report, Temple spokesmam Jeremy Walter said that the inspectors visited the Episcopal campus as a result of an anonymous complaint.
Although the complaint proved to be unfounded, the inspectors found other issues, Walter said. Stating that those issues were "quickly remedied," he added that "there were no untoward patient outcomes."
Temple also filed a corrective action plan in which it promised to revise policies for the use of restraints,implement an auditing program to ensure it is being followed and educate staff. State officials accepted that plan.
According to the inspection report, the state surveyors found that on Dec. 2 of last year two patients were placed in four point restraints but "there was no evidence" that less restrictive alternatives were considered.
The same was true, according to the report for three other patients placed in four point restraints later in the same month.
In one of those cases, the report states, there was no indication that there was an effort to discontinue the restraints at the "earliest possible time."
Another patient remained in restraints even though he or she was cooperative and had slept for two hours. In yet another case, surveyors found that there was no evidence of compliance with a requirement that there be constant monitoring of patients while being held in restraints.
The facility also was faulted for referring victims of sexual assault to another facility when they were required "at a minimum" to perform a forensic exam and utilize a rape kit.
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Crozer Burn Unit Cited on Hygiene

By Walter F. Roche Jr.

The burn treatment unit at a Delaware County hospital that bills itself as "a national leader in burn care,"has been cited by state inspectors for failing to follow required infection control practices, including compliance with basic hand hygiene.
In a 39-page report recently made public, the state Health Department also found that for years the hospital has been using the wrong liquid to flush hoses used in the treatment of burn patients.
Since 2006, the report states, hospital staffers have been using chlorhexidine instead of bleach to flush hoses in the hydro therapy room.
Although staffers were required to immediately decontaminate their hands after removing gloves between patient contacts, the state surveyors found that practice was not always followed.
"I witnessed a physician scratch his nose and scalp, put on personal protective equipment and then enter a patient's room," a hospital employee wrote in an email exchange.
The same employee, who was conducting a hygiene compliance audit, wrote that when two residents attempted to follow the doctor into the same patient's room wearing only a gown "I asked them to wash their hands prior to entry and they stated, 'We never had to wash our hands before,'"
Andrew Bastin, a Crozer spokesman, said the facility would be filing a corrective action plan by the April 1 deadline.
"Crozer-Keystone Health System is committed to providing exceptional care with an emphasis on patient safety. Routine inspections from the Pennsylvania Department of Health are a valuable way to identify opportunities for continued improvement," he wrote in an email.
In their report, the state surveyors noted that despite prior internal findings that the expected 100 percent compliance with hand hygiene practices was not being achieved, no action was taken by patient safety and a local governing body.
quality panels established to ensure standards were being met.
"There was no documentation of any actions taken by the local governing body with regard to the staff's failure to meet the benchmark for hand hygiene compliance of 100 per cent," the report states.
In fact the hospital's own audit records showed the hand hygiene compliance rate declined from October of 2016 to October of 2017.
As for the hospital's governing body, the report states that the panel "failed to ensure that the patient's right to care in safe environment was maintained."

Washington County Home Cited, Fined

By Walter F. Roche Jr.


Tennessee health officials have ordered a Washington County nursing home to cease admitting any new patients after state inspectors found multiple violations at the facility.

The order and fines totaling $6,000 against the Family Ministries John M. Reed Center in Limestone were announced today by state Health Commissioner John Dreyzehner. The facility is licensed for 63 beds.

The commissioner said the violations were uncovered in three areas; nursing services, medical records and pharmaceutical services.

In addition he said a state monitor has been appointed to oversee operations at the home.

Philadelphia Hospital Cited on Life Safety

By Walter F. Roche Jr.

A major Philadelphia hospital has been cited for multiple deficiencies following a Medicare inspection of fire protection and other building safety requirements.
The four day January review at Pennsylvania Hospital found deficiencies in several buildings including missing fireproofing on structural beams, fire alarms that were partially inoperative and exposed electrical wires.
The 520-bed hospital, part of the University of Pennsylvania Health System, was inspected from Jan. 9 to Jan. 12 for compliance with provisions of the federal Life Safety Code.
Asked for comment, a Penn Medicine spokeswoman said," We worked to correct the items in the report as quickly as possible as well as put alternative protections in place to ensure the safety of all occupants."
She said the state findings "were part of a routine regulatory inspection," adding they were "very common in an active occupied hospital building. At Penn Medicine, patient safety is our number one priority."
Other findings include the failure to maintain the fire resistance rating of common walls and or on stair tower enclosures.
On the sixth floor of one building a door failed to positively latch. In several locations the state inspectors found unsealed penetrations. At another location they found a fire alarm system component with an inoperable component.
A review of fire sprinkler systems found that some gauges had not been serviced within the five year limit. Smoke compartments in some sleeping locations exceeded the maximum area.
According to the report, structural steel in the neurosurgery building lacked fire protection.
Also cited was the fact that the control panel for a fire alarm system in one building was located in a basement under lease by another party, raising concerns about accessibility in the event of an emergency.
In a parallel Medicare review of patient care, inspectors cited the hospital for failure to dispose of expired medications.
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