UPMC Cited in Patient Death

By Walter F. Roche Jr.

Multiple errors by staffers at a major Pittsburgh hospital led to the death of a cardiac patient, according to a report by the Pennsylvania Health Department.
The 18-page report on UPMC Presbyterian Shadyside just made public this week states that one patient was found dead several hours after a cardiac monitor became disconnected.
The patient, who was suffering from coronary artery disease, was admitted on May 24 at 9:52 a.m.
A cardiac monitor was ordered at 5:23 p.m., but it didn't become active till 7:45 a.m. the next day. A review of records showed the lead became unplugged at 11:32 a.m., but no action was taken despite an alarm going off.
The patient was found at 3:52 p.m. without a pulse.
"No alarm was triggered to alert staff that MR1 (the patient) had an acute event that required an emergent response," the report states.
The facility "failed to ensure there was sufficient nursing supervision to ensure the patient's cardiac status was continuously monitored," according to the report.
In fact a review of records for 11 cardiac patients showed staffers failed to conduct twice daily cardiac assessments.
In the cardiac patient's case, the hospital also was cited for failing to inform the family about what had happened within seven days of the discovery of the reportable event. The family was finally informed on June 27
The surveyors noted that the hospital also failed to notify the family of another deceased patient (MR12) of the adverse event within seven days.
"Review of MR12 revealed a serious event causing a return to the operating room and contributory to the patient's death was identified on April 3. Review of family notification revealed a letter to the family dated June 3," the report states.
The hospital also was cited for the care provided to another patient who ended up in kidney failure
The report states that the patient had normal kidney function when he was admitted, but suffered acute renal failure when staffers failed to monitor test results as ordered by a physician.
Dosing and blood levels, the report states, were consistent with vancomycin poisoning.
The hospital "failed to administer drugs and biologicals according to a physician's order," the state inspectors reported.
The hospital filed a plan of correction including immediate re-education of staff on the requirements for cardiac and test monitoring. Under the plan audits are to be conducted to assure staff compliance.
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Staffing Levels Critical at Johnstown Hospital

By Walter F. Roche Jr.

"It's only a matter of time until someone really gets hurt or we lose a baby."
That's what one employee of the Conemaugh Memorial Medical Center told a surveyor from the Pennsylvania Health Department during a recent investigation of chronic staff shortages in the obstetrical department.
The employee was only one of more than 10 who told the surveyors that conditions in the department were at the breaking point.
"We're all afraid of retaliation. Many of our patients are at risk," another employee said, adding that some employees were working "80, 90, or 100 hours per week."
The complaints and concerns were included in a recently released report from the state health agency.
"The facility failed to ensure that a sufficient number of nursing personnel were assigned to provide nursing care needs of patients," the report concludes.
The report also cites the facility for failure to complete a series of required forms when staffers were assigned to work beyond their regularly assigned hours.'
The report stops just short of concluding that the hospital was in violation of a 2009 law placing limits on the number of overtime hours direct care staffers can be required to work. Surveyors did conclude that a review of staffing records showed multiple shifts were not staffed according to the hospital's own staffing guidelines.
The hospital did file a plan of correction in which it promised to hire additional registered nurses and to implement monitoring and audit programs to ensure that sufficient staffing was maintained.
The employees interviewed by the state also cited high turnover of staff due to the increased hours.
"Staff is very unhappy," one employee related noting that staffers were often forced to work a full 12 hour shift without even a lunch break.
"This is the worst it's ever been," a veteran staffer stated, citing a "vicious cycle" when frustrated employees quit leaving the remaining staff with even more work.
The surveyors found that between Jan. 1, 2018 and March 22. 2019 there were 77 instances when staffers were required to work beyond scheduled hours.
The report is not the first in which state health officials questioned the adequacy of staff levels. Two recent reports raised the same issue at two Wilkes Barre health facilities.

Contamination In Pittsburgh Area Hospital OR

By Walter F. Roche Jr.
Pennsylvania surveyors have cited a 200-bed hospital for two instances when contamination was found in an operating room forcing delays in scheduled procedures.
The recent report on the Allegheny Valley Hospital also detailed two instances when facility employees failed to get proper informed consent for surgical procedures. According to the report the hospital did not file a plan of correction for multiple deficiencies.
The report, based on a June 20 visit to the Natrona Heights hospital, focused on a May 13 event when a hospital staffer discovered a piece of bone on a tray needed for an upcoming surgery.
"The tray was then contaminated," the report states.
Another patient record showed staffers in the operating room discovered blood in a depth gauge forcing a delay in that surgery.
In two other cases the state inspectors concluded that surgeries were performed without proper prior consent.
In one case a surgeon repaired a hernia while the consent form showed the patient had consented to surgery for the removal of "a groin mass."
"There was no documentation that the surgeon talked to the family," the report states.
In the second case the report states that there was no mention in the consent form of "a debridement of a wound" on the patient's right heel, which is what occurred.
The state inspectors also reported personally observing on June 18 four staffers in operating rooms without their hair properly covered.
Yet another deficiency cited was the lack of proper operative records in four of eight records reviewed.
The report also faulted the hospital for the failure to record fluid loss in four operative records.
An examination of operating room files showed proper and required operative records were missing in four of eight cases.
According to the report the hospital also failed to "perform air exchange testing on all required areas of the facility.
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Rural PA Hospital Cited for Deficiencies

By Walter F. Roche Jr.

A rural Pennsylvania hospital has been cited for multiple deficiencies including failure to properly sanitize reusable medical equipment and properly dispose of outdated narcotic medications.
In a report based on a May 21-24 visit to the Susquehanna facility surveyors from the state Health Department concluded that the 83-bed Barnes-Kasson County Hospital did not meet the requirements for participation in the federally funded Medicare and Medicaid programs.
The report comes at a time when rural hospitals across the country have been forced to cut back services and even shutdown due to decreased funding.
The first item cited in the newly released report was the failure of the hospital to post a notice informing patients and visitors that there is not a doctor on duty 24 hours a day and seven days a week.
The inspectors also found that the facility did not follow proper procedures in sanitizing reusable medical equipment such as an endoscope. Test strips used to test the equipment were not dated to show when the package was opened. In addition the staffers failed to monitor and record temperatures during the sanitation process as required.
Outdated narcotics were observed at the hospital but those drugs had not been listed on a log of drugs scheduled to be disposed through an outside vendor.
In the dietary department hair of employees was not properly restrained and workers did not change gloves after touching their hair.
In the surgical department surveyors found that in three out of three operating rooms anesthesia staffers were not properly supervised.
Still other deficiencies included the failure of the quality improvement department failed to review data on falls, medication errors and problems with intravenous (IV) administration.
According to the report between Jan. 1, 2019 and May 24 there were 10 falls, 12 medication errors and 14 IV infiltrates. Infiltrates occur when medication in the IV leaks into surrounding tissue.
The hospital filed a plan of correction addressing each of the deficiencies including staff retraining and monitoring to ensure staffers are following required procedures at the hospital..
The plan also includes new signage informing patients a doctor is not always present.
Hospital officials did not respond to a request for comment.
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Hospital Rejected State Records Request

By Walter F. Roche Jr.

When state surveyors showed up at a rural Pennsylvania hospital and asked to look at patient safety and related records they were told they couldn't have them because the records were "confidential and protected."
In fact on three successive days in early June the state surveyors got the same response from officials of the Guthrie Towanda Memorial Hospital. On the next try they were given records but with large sections blacked out.
Left unreadable were sections of the minutes covering discussions and conclusions.
The confrontation earned the 35-bed hospital a citation for failing to comply with state licensing requirements.
"The facility was not able to provide this information because the information was considered confidential and protected," the inspection report states.
The records requested were meeting minutes for committees the hospital is required to maintain for patient safety, performance improvement and infection control.
Subsequently the hospital, located in Towanda, filed a plan of correction in which they promised to provide unredacted copies of the requested minutes by July 30.
The hospital was also cited for installing new imaging equipment without first notifying the state.
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PA Hospital Surrenders License

By Walter F. Roche Jr.

A tiny Pennsylvania hospital specializing in bariatric surgery has closed its doors and surrendered its license to state health officials.
Once part of a nationwide chain, the Bucks County 23 bed facility was part of Barix Clinics. The only remaining facility is located in Ypsilanti, Michigan.
Known as the Forest Health Medical Center, the Pennsylvania facility has been the subject of critical inspection reports by state Health Department surveyors. In one recent report surveyors noted the facility had gone 150 days without a single patient.
The latest report on the Langhorne clinic is the notation that the facility "relinquished" its certificate of licensure.
A closure inspection was completed on June 19.
Several deficiencies had been cited when the facility underwent a Medicare re-certification in 2018. The Barix company signed a settlement agreement with the federal government in 2013 after investigators found that two HIV positive patients had their surgeries canceled when the test results came in.
The Bucks County hospital has posted a notice on its web site blaming the closure on the refusal of insurance companies to provide adequate patient coverage
"Over the past 15 years, insurance reimbursement to small specialty hospitals has declined significantly. After several years of losses we chose to close rather than drastically cut costs and compromise our unwavering commitment to providing the best patient care. We are sorry for any inconvenience this may cause," the notice states.
Following the critical inspection report the hospital did not file a plan of correction acceptable to the state.
"The facility failed to function as a hospital," the report states, noting that the average daily census ranged from 1.2 to 3.3 patients.
The building at 289 Middletown Boulevard in Langhorne has been sold to Capital Health Primary Care.
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