Surgery Patient Burned at Scranton Hospital

By Walter F. Roche Jr.

A Scranton hospital failed to properly investigate a serious incident in which a patient was burned during a routine surgical procedure, according to a state Health Department report.
The patient, who was undergoing an obstetrical procedure at the Geisinger Community Medical Center, was burned on the upper left thigh when an instrument became disconnected and a cord struck the patient's leg.
"The facility failed to complete an investigation regarding a patient sustaining a burn during a surgical procedure," the report states, adding that the failure amounted to a violation of the state Medical Care Availability and Reduction of Error Act.
State surveyors who visited the 279 bed facility in August also reported that the hospital's patient safety committee also failed to investigate a "serious event."
The patient was injured in early April but when the state inspectors asked for a copy of the investigative report "none was provided."
Also cited in the report was the failure of nursing staff to document a description of the patient's injury. The report states that the wound was 1.5 to 2 centimeters in diameter when the patient was examined by a doctor a little over a month after the incident.
The hospital filed a plan of correction in which it agreed to re-educate staff on the types of incidents that must be investigated and the proper method of conducting such an investigation.
A hospital spokesman said s subsequent investigation showed that "user error" and not equipment failure led to the incident. He said the patient was informed of what happened and the plan of correction was implemented.
The report is the third in recent months to cite a Geisinger hospital. The Geisinger Wyoming Medical Center in Wilkes Barre was cited for failing to immediately assign staff to maintain a constant watch on a suicidal patient. In the third incident Geisinger Wyoming was cited for failure to perform a physician ordered test.

Philly VA Faulted in Death

By Walter F. Roche Jr.

Multiple failures at a Veterans Administration facility in West Philadelphia may have contributed to the unexpected death of a drug dependent patient in late 2017, according to a report issued today by the VA's Inspector General.
According to the report the failures continued even after the unnamed veteran in his mid-30s had passed away on his 10th day of treatment.
The report states that the drug dependent veteran was being treated with methadone after testing revealed elevated levels of oxycodone. He had been sent to Unit 7E, a 20 bed acute behavioral mental health unit.
Citing failures to communicate and failure to respond to symptoms of over-sedation, the IG concluded that opportunities for early intervention were squandered.
The staff failed to monitor EKG changes and did not adequately investigate possible adverse drug interaction, the IG found.
On the day of his death, the IG found, two care givers gave conflicting reports in patient records on the amount of methadone actually administered on that critical day.
And when the patient was found unresponsive on the 10th day of treatment, "Unit 7E was not adequately prepared to effectively respond to the patient's cardiac arrest."
Though some corrective changes were implemented after the 2017 death, the IG found the investigation was deficient because two key caregivers were involved in the analysis.
The Root Cause Analysis of the incident failed to comply with Veterans Health Administration requirements because two caregivers were involved in the analysis, thus creating the possibility of bias.

Geisinger Wyoming Gets 2nd Citation

By Walter F. Roche Jr.

For the second time in a matter of a month, a Wilkes Barre hospital has been cited by state regulators for failing to comply with minimum standards.
In a report just made public by the state Health Department, surveyors charged that staffers at the Geisinger - Wyoming Medical Center failed to assign a person to constantly monitor a patient who had expressed thoughts of suicide.
"A patient has a right to receive care in a safe setting," the report on the 286 bed hospital states.
The same facility was cited in June for failing to complete a blood test ordered by a physician for a patient who suffered a stroke days after the test was postponed.
According to the latest report state inspectors declared a state of immediate jeopardy on Aug. 2 after they reviewed hospital records on the care provided to the suicidal patient.
The patient had admitted to having suicidal thoughts "related to her medical condition and chronic pain."
Although the patient's condition mandated that a sitter be assigned to provide constant watch there was "no documentation that a sitter was ordered."
At 12:58 p.m. on July 25 a nurse entered the patient's room to find the patient had a call bell wire held very tightly across her neck. Only then was a sitter assigned to keep the patient under constant watch, according to the state report.
A Geisinger spokesman said that when the patient first came to the hospital she was properly screened and judged not at risk for suicide and not in need of a sitter.
"Days later, when the patient’s change in mood constituted reason for concern, a psychiatric consultation was performed, and a 1:1 sitter was recommended. Before the sitter could be assigned, a provider re-entered the patient’s room and found the patient exhibiting behavior that suggested self-harm," the spokesman continued.
From that point on the patient was not left alone, according to the spokesman, who added that the hospital self-reported the incident to the state.
The hospital's two first plans of correction were rejected as inadequate. The third version was accepted and the state of immediate jeopardy was finally lifted at 5:43 p.m. In that third plan the hospital agreed to make the assignment of a sitter automatic with specified diagnoses. If a sitter is not immediately available a nurse must remain with the patient until a sitter arrives. The plan also calls for audits to be performed to ensure staff are following the revised procedures.
The spokesman said the action plan approved by the state allows for easy implementation of suicide precautions and assignment of sitters.
Contact: wfrochejr999@gmail.com

Geisinger Cited for Missed Test

By Walter F. Roche Jr.

When a patient reported to the Geisinger Wyoming Valley Medical Center for the blood test ordered by a doctor, the laboratory personnel turned the patient away, canceling the appointment. Two days later the patient was back at the hospital suffering from a stroke.
The test that wasn't completed, according to a state Health Department report, was "a test used to diagnose bleeding or clotting disorders and to monitor the treatment with blood thinning medications."
The patient's test was cancelled on June 19. The stroke came on June 21.
A review of the hospital records showed the patient arrived at the hospital emergency department "with signs and symptoms of a stroke." The patient had right vocal chord paralysis, tongue dysphagia and severe expressive aphasia.
"The facility failed to ensure a physician ordered laboratory request was completed," the report states.
"The medical test in question was submitted for instrument analysis; however, the lab result was omitted due to an isolated technical issue," a hospital spokesman said, adding that the patient was informed of the incident.
"Our patients come first at Geisinger, and we work daily to do what is best for them," the spokesman added.
The report by state surveyors who visited the 286 bed Wilkes Barre hospital in early August also cited the hospital for failing to perform a root cause analysis of the incident, a routine procedure to prevent a recurrence of medical errors.
According to the report, by the time the investigation was initiated on June 28 the history from the laboratory analyzer had been removed and "it was too late to download the files." And there was no thumb drive back up.
Surveyors interviewed other hospital employees who said the lab employee never asked for additional information needed for the investigation to continue.
The hospital filed a plan of correction with provisions for the special handling of high priority requests. The plan also includes re-education programs for staff and a series of audits to ensure proper procedures are being followed.
Contact: wfrochejr999@gmail.com

Immediate Jeopardy at Pocono Hospital

By Walter F. Roche Jr.

State surveyors officially declared patients at a Pennsylvania hospital were in "immediate jeopardy" two times over a two day period because physician ordered cardiac monitors for critically ill patients were not being monitored.
The details of the July visit to the 237 bed Lehigh Valley-Pocono Hospital are spelled out in a report just made public by the state Department of Health.
The hospital, the report states, "failed to ensure that patients were provided continuous telemetry monitoring for 36 of 36 patients requiring physician ordered monitoring."
In fact a review of patient records at the East Stroudsburg, facility found multiple cases in which monitors recorded critical changes in a patient's heart condition which produced no response from hospital staff.
Federal regulations define immediate jeopardy as a situation in which actions or in-actions by hospital employees "placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death."
Once a declaration is issued, health providers are required to respond immediately.
According to the report the state survey team declared the first immediate jeopardy at 2:06 p.m. on July 15. That was just 41 minutes after they arrived at the hospital. At 2:46 p.m. the survey team rejected the hospital's first plan of correction. A second plan of correction was submitted at 4:06 p.m. but it also was rejected. A third plan of correction was submitted at 5:22 p.m. and it was accepted at 6:30 p.m.
The immediate jeopardy was back in place at 11:25 a.m. the next morning when surveyors once again found that telemetry monitors were not being continuously monitored.
It was finally lifted at 2:20 p.m. on July 16.
The teams' review of records showed one case in early July when a patient experienced 14 beats of ventricular fibrillation recorded on a monitor, but there was no response from staffers. No vital signs were taken and the physician was not informed, according to the report.
Ventricular fibrillation, the report states, is "considered the most serious cardiac rhythm with the potential to cause cardiac arrest."
Another patient experienced atrial fibrillation, but again there was no response by hospital staff
During the review team's time at the hospital they observed that in three of four cases patients experienced changes in heart rhythms but no staffers responded, even when one of the monitors was alarming.
The corrective action plan finally accepted and put in place by the hospital calls for non-nursing personnel being assigned to constantly monitor all monitors but only after they are educated on the proper procedures.
"They (non nurse personnel) may not be in charge of monitoring," the plan states, adding that monitoring will be their only assignment and they are not to perform other duties.
Contact: wfrochejr999@gmail.com

Patient Got Wrong Blood Type

By Walter F. Roche Jr.

A pregnant 33-year-old patient was transfused with the wrong blood type at a Hazelton hospital when two nurses failed to verify her name and blood type prior to initiating the transfusion.
A recently released report from the Pennsylvania Health Department details the error which occurred in January at the Lehigh Valley Hospital-Hazelton. The seven-page report indicates the error did not cause any harm. The hospital did not immediately respond to a request for comment.
The patient, who was 24 weeks pregnant, was brought to the hospital on Jan. 8 by ambulance minutes after midnight. According to the report she had severe bleeding and was pale and shivering on arrival.
Though she had no active bleeding on arrival she had extensive vaginal bleeding the night before and was experiencing uterine contractions. She was placed on a heart monitor and a blood transfusion was ordered, the report states.
The records showed there were "positive fetal heart tones and positive fetal movement."
The patient's blood type was O Positive, but when a transfusion was ordered she was transfused with B Positive blood.
"There was no documentation that two registered nurses verified the patient name, date of birth and blood type prior to the administration of the blood," the report states.
"There was documentation MR1 (the 33-year-old patient) received one unit of B Positive blood which was intended for another patient in the emergency room," the report continues.
The surveyors reported that the transfusion was "stopped immediately," adding that records showed the error had no deleterious effect on the patient.
She was subsequently transferred to a tertiary care hospital in stable condition.
The hospital filed a plan of correction in which it agreed to conduct re-education sessions with staffers and revised procedures to ensure that a double check was performed prior to any transfusions.
Contact: wfrochejr999@gmail.com

2nd UPMC Hospital Cited in Death

By Walter F. Roche Jr.

For the second time in a matter of days a western Pennsylvania hospital has been cited for failing to monitor a cardiac patient who was later found dead and unresponsive.
In a report made public this week state health surveyors found that a patient at UPMC McKeesport who was supposed to be on a cardiac monitor, was found "slumped over and pulseless" on June 1. Records showed the monitor had become disconnected some three hours earlier but no one responded.
"Time of death was 2:10 p.m.," the report states
That was just days after a similar incident at UPMC Presbyterian Shadyside in which a cardiac monitor became disconnected but no action was taken. That patient was also found dead several hours after the monitor went dark.
In the McKeeport case the health department report states that the patient was admitted on May 31 with a complaint of back pain. A physician ordered a cardiac monitor for May 31 and June 1.
Hospital records show the unnamed patient was discovered with no heartbeat at 1:58 p.m. on June 1. Resuscitation efforts failed and death was declared 12 minutes later.
The hospital also was cited for failing to conduct required cardiac rhythm assessments for the patient and three other cardiac patients in the same time period.
The hospital was also cited for failing to notify state health officials of a serious event within 24 hours of its discovery.
The report dated July 22 was the result of two visits to the facility and was described as an "unannounced special monitoring survey."
The hospital filed a plan of correction in response to the inspection in which it promised a re-education program for staffers on the requirements for cardiac monitoring and assessments for cardiac rhythms.
The Mckeesport report parallels the 18-page report issued on the May 25 UPMC Shadyside incident in which a patient was found unresponsive several hours after the cardiac monitor had became disconnected.
Records showed the monitor lead became disconnected at 11:32 a.m. but no action was taken. The patient was discovered pulseless at 3:52 p.m.
In that case the hospital was also cited for failing to notify the victim's family of the adverse event within seven days.
Contact: wfrochejr@gmail.com