Wilkes Barre Hospital Understaffed?

By Walter F. Roche Jr.

A specialty hospital in Wilkes Barre "showed a systemic nature of non-compliance with nursing services," according to a report from the Pennsylvania Health Department.
The highly critical report, the result of three recent visits to the PAM (Post Acute Medical) Specialty Hospital, cited multiple deficiencies in the care provided to patients by the nursing staff.
Six patients were not re-positioned every two hours as ordered, five patients missed weight checks and no assistance was provided a patient who needed help in feeding.
The facility "failed to ensure that nursing administration provided oversight of nursing services," the report states.
The 36-bed unit is located within the Wilkes Barre General Hospital.
Still other deficiencies included failure to check glucose levels before insulin injection, failure to bathe four patients, delays in performing dietary assessments, and failure to send a patient's record to the emergency room along with the patient. The patient ended up in intensive care suffering from acute respiratory failure.
Other records, the surveyors reported, were filled out in advance and inaccurately.
"The nursing service must have adequate numbers of licensed registered nurses and other personnel," the report states
Also noted in the report was the fact that the state surveyor slipped on a wet floor which had no signage.
A plan of correction filed by the hospital includes retraining of staffers and audits to ensure compliance with standards.
The report noted that the hospital failed to implement a prior plan of correction filed earlier this year in response to another critical inspection report.
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State Begins Transplant Reviews

By Walter F. Roche Jr.

The Pennsylvania Health Department has resumed its role of inspecting transplant programs across the state for compliance with federal standards and two facilities at opposite ends of the state have already been reviewed.
In reports recently made public state health surveyors found one deficiency at an Allentown hospital and concluded that a Pittsburgh facility met federal transplant requirements.
The deficiency was found at the Lehigh Valley Hospital while the Allegheny General program was judged in compliance with standards.
The responsibility to examine transplant programs shifts every three years from the U.S. Centers for Medicare and Medicaid Services to state health agencies. The last reviews of transplant programs by the state took place from 2010 to 2012.
The Allegheny General review took place in April while the Lehigh Valley review took place in mid-June.
At Lehigh state surveyors found that the person assigned to the job of "Living Donor Advocate" was the same person serving as a transplant social worker.
"The Living Donor Advocate," the report states, "must not be involved in transplant issues on a routine basis."
Hospital officials questioned during the June inspection said they had tried to limit the interaction between the advocate and the transplant team.
In a plan of correction hospital officials said the job of the living donor advocate was being shifted to a different department and a new policy would be put into effect ensuring that the advocate was not connected to the transplant team.
Brian Downs, a hospital spokesman, said the issue already has been resolved with the appointment of a new donor advocate.
The Allentown hospital was reviewed for two transplant programs, adult kidney and adult pancreas.
The spokesman said the hospital's transplant program has been in operation for 28 years and about 100 transplants are performed per year.
Allegheny General's transplant program includes heart, kidney, pancreas and liver.
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Hospital Failed to Probe Alleged Drug Loss

By Walter F. Roche Jr.

A Cumberland County hospital has been cited for failing to investigate a complaint by a patient that some 240 oxycodone tablets had disappeared when she sought to recover them at the time of discharge.
The 16-page report recently made public by Pennsylvania health officials states that officials of the Encompass Health Rehabilitation Hospital of Mechanicsburg didn't even record the complaint from the patient's family in a facility complaint log.
The facility "failed to conduct a timely and comprehensive investigation of a complaint presented by the family of Patient MR1."
The patient had been admitted to the 75-bed facility in early April, but upon her discharge on April 19 the family was told the pills were not among her possessions.
A review of hospital records by state surveyors showed that a patient form to record any possessions at the time of admission was left blank and never filled out for the patient.
In fact the inspectors concluded the hospital did not even have "step-by-step" policies and procedures in place for staff to follow during the admissions process.
In the plan of correction filed by the hospital, the facility administrators said they have since put in place procedures to be followed during the admission process. They said they also counseled and re-educated staffers on the proper procedures,
In the future the hospital said if a patient arrives with prescription drugs not prescribed by a staff physician, the drugs will be sent back with the patient's family
When a hospital employee was asked why the complaint had never been investigated or reported, the response was "We never had those medications in the first place."
The report also faults the facility for failing to report the suspected drug diversion to the state Attorney General of the state health authority.
In its response hospital officials said they had checked with the state Attorney General's office and were told the matter did not need to be reported. The hospital did file a belated report to the state Patient Safety Authority.
In an unrelated finding the inspectors stated that the facility was out of compliance with other state requirements because medical staffers were not on-site after 8 p.m. every day.
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PA Nursing Home Cited for Abuse

By Walter F. Roche Jr.

A Philadelphia nursing home that gained unwanted fame in the death of the father of a Trump administration official, has been cited by state health officials for subjecting patients to verbal and mental abuse.
In a recent report inspectors from the Pennsylvania Health Department concluded that employees of the 133-bed nursing home at Cathedral Village subjected at least three residents to verbal and mental abuse.
One patient was told she was "too fat," and "I am getting you out of bed whether you like it or not."
The nursing home, owned by Presbyterian Senior Living, was cited a year ago in the death of Harold McMaster Sr., father of former Trump administration security advisor Harold McMaster Jr. The elder McMaster died following a series of falls at Cathedral Village. A Cathedral Village employee, Christann Gainey, assigned to care for the patient was subsequently charged with neglect, tampering with records and involuntary manslaughter. Her trial is scheduled for Oct. 19.
A subsequent state inspection report faulted administrators at the facility for multiple violations of state and federal regulations.
The recent inspection report dated May 17 was conducted to determine Cathedral Village's compliance with federal standards for the Medicare and Medicaid programs.
In addition to the woman who was told she was too fat, an incontinent male patient was told that if he soiled his bed again, he'd be left to sit in it.
"I am not going to change your sheets again today," the employee told the patient.
Before the incident the patient had confided to other workers that he was afraid he was going to be in trouble.
The abuse incidents, according to the 40-page report, were verified by other Cathedral Village staffers.
Still another patient was told to go in her brief when she asked to be taken to the bathroom. According to the report the woman was in tears when the day shift arrived.
Other deficiencies include failing to promptly inform the physicians and family representatives of a change in a patient's condition.
In one case nursing home staffers failed to inform the patient's doctor of laboratory results showing a serious change in the patient's condition.
In another case the nursing home failed to have tests performed on a patient as ordered by the physician. Another patient did not get prescribed oral care.
The facility officials filed a plan of correction in which they contended that patients did not sustain any "lasting harm" from the lapses in care. They did promise to conduct retraining programs for staffers and to conduct audits to ensure that rules were being followed.
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PA Hospitals Cited on Restraints

By Walter F. Roche Jr.

Two Pennsylvania hospitals located at opposite ends of the state have been cited by state Health Department surveyors for misuse of restraints, a recurring problem at health facilities.
UPMC Altoona and Nazareth Hospital in Philadelphia's Northeast were cited in reports recently made public.
In Altoona state inspectors found that a patient had been placed in a locked seclusion room without any medical or safety justification.
Citing the facility's own policies barring the use of restraints or seclusion for the convenience of hospital personnel, the surveyors determined the patient, who posed no threat to self or others, was kept in the locked room for an undetermined length of time.
When one employee of the facility was questioned she said that she was making a periodic check of the emergency area in February, "I noticed that someone was in the seclusion room. The door was locked and I walked in.Once we investigated," the employee contiued, "It was determined this patient should have never been placed in locked confinement."
The employee told the state inspector there was no medical justification for placing the patient in a locked room.
In addition although the seclusion room was supposed to be under 24 hour camera surveillance there was no tape of the session in question.
The surveyor also noted that the surveillance monitors could be viewed by patients or visitors, thus violating privacy rights.
The survey also noted there was no call bell in the seclusion room.
In a plan of correction filed by the hospital, officials promised to implement a re-education and monitoring program to ensure hospital policy was being followed.
At Nazareth Hospital an April visit by state health surveyors showed 10 patients had been placed in restraints without a required physician's authorization. In a related deficiency, the state inspectors found that the hospital failed to perform the required periodic reviews of the need for restraints to be continued.
Nazareth was also cited for leaving patients in hallways in the emergency area for excessive periods. The limit, according to the report is six hours but one patient was kept in a hallway for some 10 hours.
The hospital filed a plan of correction in which it promised to file the required infrastructure reports, re-educate staff and conduct daily reviews on restraint use.
The report also cited the hospital for failure to report an infrastructure failure - the lack of available beds- to the state.
Neither hospital replied to questions or a request for comment.
The two facilities are hardly the first in Pennsylvania to be cited for over-use or misuse of restraints. Among other facilities cited for the same deficiency is the Washington Hospital in Washington County.
That facility was cited for placing three patient in handcuffs without a physician's order.
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VA Mishandled Dead Vet's Discharge

By Walter F. Roche Jr.

Multiple failures at a Veterans Administration facility may well have contributed to the 2017 death of a veteran who died just eight days after his release from an agency hospital.
The details of the veteran's case, including a major medication error, were spelled out in a 50-page report from the VA Inspector General issued this week.
The name of the victim and the facility where he was under treatment were not disclosed but the report states that the VA facility was in the VA's VISN 4, a region which includes the state of Pennsylvania and parts of Delaware and New Jersey.
The IG did report that the original anonymous tip -that the veteran committed suicide two days after his discharge- was not correct.
According to the report, the veteran was released from the VA hospital only to be taken into custody at a federal detention facility where he was to face federal charges for an incident with a VA employee. He died from hypertensive and atherosclerotic cardiovascular disease, the report states.
Both before and after the discharge, the report states, officials at the facility failed to properly handle the case and provided false information about the patient's drug regimen, completely omitting one key drug, benzodiazepine. The dosage for another key drug the patient was getting from the VA was listed at only one fifth of the amount actually prescribed.
Citing the veteran's underlying cardiac condition, the report concludes that the misinformation about the drug dosages would likely have caused withdrawal symptoms leading to increased blood pressure which "may have contributed to the patient's hypertension related death."
In addition to the false drug information, the IG found that the VA facility failed to communicate with the receiving federal facility or the patient's family. (The only federal correctional facility in the region is located in Philadelphia).
The report also found that facility officials did not inform the veteran or his family of his rights to appeal the decision to discharge him to federal custody. The veteran had requested to be returned to a VA community living center where he had previously resided.
The facility "failed to engage in proper discharge planning" and "failed to engage in proper treatment planning," the report concludes.
David Cowgill, a VISN 4 spokesman, said the recommendations included in the audit report already were being implemented and completion is expected early next year.
"Additionally, the facility has assigned Veterans Justice Outreach Coordinators to serve as liaisons between the staff at the medical center and staff at the correctional facility in the event that any other veteran is incarcerated following discharge," Cowgill wrote in an email response to questions.
According to the IG's report the veteran was schizophrenic and had a long history of involvement in the VA's health system including lengthy stays in agency facilities. He was described as being in his fifties.
Citing "multiple failures of communication," the report says facility officials failed to follow agency rules on voluntary and involuntary commitments and at one point allowed the veteran to voluntarily commit himself even though there were literally dozens of notations in his record indicating he was not competent.
"The patient's cardiac condition warranted close monitoring," the report states, "and there was no evidence that the facility staff provided this information" to the staff at the federal correctional facility.
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Brandywine Cited in Suicide Attempt

By Walter F. Roche Jr.

A Chester County hospital has been cited by Pennsylvania health officials for failing to report a suicide attempt by a patient waiting to be seen in the facility's emergency department.
In a report issued last week state health surveyors said the incident took place at the 171 bed Brandywine Hospital in late April.
The Coatesville hospital "failed to report an event which could seriously compromise quality assurance or patient safety."
According to the report the unnamed patient was in the emergency department waiting area when she left to go to a restroom and attempted to commit suicide by tying the strap of her purse around her neck.
The incident was not reported to the state as required, but hospital officials contended they did not need to because the patient had not yet completed the registration process and was not considered a patient.
According to the state, the facility, part of Tower Health, has not yet filed an acceptable plan of correction. Hospital and Tower officials did not respond to requests for comment.
In the same report state surveyors cited Brandywine for treating patients in hallways thus violating their privacy rights. One of the patients was actively vomiting while others were undergoing treatment or examination in open view.
The hospital also failed to notify three of six patients of their rights under the federal Medicare plan.
Brandywine was also cited a year ago for failing to report a case of suspected child abuse.
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