Monday, October 28, 2019

Hospital RN Shortage Triggers Walkaways


By Walter F. Roche Jr.

Nearly a dozen patients at a rural Pennsylvania hospital apparently gave up and walked away after waiting an extended time to be seen in the emergency room.
A state inspection report on the Conemaugh Miners Medical Center cited the facility for failing to ensure the availability of nursing personnel for initial assessments.
Of the 11 patients who walked away was a psychiatric patient who ran away multiple times and was finally found hiding in nearby woods.
State surveyors also cited the hospital for failing to identify a patient who was at risk for self harm and for failing to initiate a one on one observation for a patient at risk for suicide.
Reviewing hospital records, the surveyors found that some patients were kept waiting for over an hour before they gave up and walked out.
Eleven patients of 30 patient files reviewed showed no initial assessments, according to the report on the 30 bed hospital in Cambria county. The hospital is part of the Conemaugh Health System.
An examination of the hospital's staffing records showed that at multiple times only one registered nurse was on duty in critical care areas including the emergency room.
Interviews with hospital employees showed a continuing and worsening problem with staffing.
"All weekend there was one registered nurse in the emergency room," one employee told state inspectors.
Records showed only one nurse was on duty for five of 42 shifts reviewed.
"We lost seven registered nurses since February. None were replaced," the surveyors were told. "Staff are getting bitter about working by themselves.
Another employee described filling out a form reporting "unsafe staffing."
"There is nothing I can do to make this better at this time," another employee said expressing frustration
The hospital filed a plan of correction in which it described renewed efforts to recruit additional registered nurses and licensed practical nurses.
Hospital officials said it was their goal to have an initial assessment performed on emergency room patients within 10 minutes of arrival.
Conemaugh is one of several Pennsylvania hospitals cited in recent months for staff shortages, particularly in emergency rooms. In fact a sister facility, the Conemaugh Memorial Medical Center, was cited last summer for severe and chronic staff shortages.
"It's only a matter of time until someone really gets hurt or we lose a baby," an employee told state surveyors.
In the most recent case a patient at York Hospital died in the emergency room when staffers assumed the patient had left when he didn't respond when his name was called. Staff shortages were cited as a contributing cause.
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Tuesday, October 15, 2019

Geisinger Facility Cited Again


By Walter F. Roche Jr.

When state inspectors visited a Scranton hospital in August they observed staffers assigned to constantly monitor patients in a mental health unit chatting among themselves and talking on their cell phones.
In addition a search of records showed another patient in the unit who was supposed to be under one-to-one monitoring was not immediately assigned a watcher. The patient had spoken about jumping off a bridge and was considered a suicide risk.
"The facility failed to ensure a staff member was performing a patient required one-to-one direct visual examination," the report states.
The recent visit to the Geisinger Community Medical Center was not the first in which state surveyors found violations of minimum state and federal standards. The same 279 bed facility was cited recently for failure to properly investigate an incident in which a patient was burned during surgery.
A Geisinger facility in Wilkes Barre also has been the subject of multiple critical reports.
In the 13-page Aug. 27 report on the Scranton facility, the surveyors also found ceiling vents that could be used in a suicide attempt and a plastic bag that also could accommodate a suicide effort.
The facility failed to ensure care in a safe environment," the report states.
In a plan of correction filed in response to the critical report, Geisinger officials agreed to quickly replace the ceiling vents and remedy other possible suicide risks.
The hospital also initiated a re-education program for workers in the behavioral unit and barred the use of personal cell phones while on duty.
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Saturday, October 12, 2019

Patient Dies Awaiting Care in Hospital ER


By Walter F. Roche Jr.

Staffers at a York,PA hospital concluded that an emergency room patient left without treatment when in fact the patient lay dying in their midst.
An investigation by state surveyors on the Aug. 16 incident at the York Hospital showed staffers passed the dying patient at least a dozen times without checking for vitals. Some passed within 1 to 2 feet of the wheelchair where the patient was seated.
The patient was brought by ambulance to the Wellspan facility at 9:59 a.m. and was discovered unresponsive hours later. The death pronouncement came at 1:31 p.m.
The hospital also was cited for failing to report the incident within 24 hours as required by state law.
Despite a hospital policy requiring periodic rounding, the state investigators review of the patient's record "failed to reveal evidence that anyone had completed rounding, while the patient was in the waiting room."
The nurse who was charged with assessing the patients waiting in the ER never even spoke to or even approached the patient, according to the report.
A review of surveillance footage showed the patient showed no movement from 11:09 a.m. to 12:20 p.m.
The patient, identified as MR1, failed to respond to three calls of his or her name.
The surveyors from the state Health Department noted that two other patients, considered in a less critical status, were treated and released in the interim.
"None of the critical protocols were initiated on the patient," the report states.
The patient had been placed in front of a triage room that was not in use at the time, according to the report.
In a response to the report, the hospital said,"The event has been taken extremely seriously at all levels of the organization."
Wellspan officials called the incident a "rare event," but acknowledged the facility failed to properly care for the patient.
A plan of correction filed by the hospital calls for a series of retraining programs and additional staffing in the emergency room.
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Friday, October 4, 2019

Pottsville Hospital Cited in Elopement


By Walter F. Roche Jr.

Multiple deficiencies in the handling of patients needing mental health evaluations were uncovered by state surveyors on a recent visit to a Pottsville hospital.
The surveyors declared a state of "immediate jeopardy" at the 129 bed Lehigh Vallley Hospital-Schuylkill in late August due to the failure to promptly institute one-on-one observation for patients deemed at risk to themselves or others.
The facility "failed to ensure the safety of patients," the report states.
The "immediate jeopardy" was lifted when hospital officials came up with an acceptable plan of correction.
In one case cited in the report a patient who had been taken to the hospital by police for a mental health evaluation was left alone in a waiting area and walked away only to be returned to the hospital by police a second time.
The hospital "failed to put patients immediately on one-to-one observation...resulting in elopements on patients who were petitioned to be at risk to themselves or others," the surveyors reported.
Also cited by the state was the failure to perform a suicide risk assessment on one patient being held on involuntary status.
The report cites the hospital's own policy requiring that a staffer be within arm's length of patients being held involuntarily.
One of the patients not placed on immediate observation had a documented history of suicide attempts.
Other items cited by the inspectors was the failure to obtain written orders for the use of restraints and failure to re-assess every 15 minutes patients being held in restraints.
In its plan of correction the hospital promised a re-education program for staffers handling mental health evaluation cases and a series of audits to ensure staff followed the proper procedures.
Another Lehigh Valley Health facility in East Stroudsburg also was hit with an immediate jeopardy declaration recently. That facility was cited for failing to have staff to constantly observe cardiac monitors.

Immediate Jeopardy (IJ) represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death. These situations must be accurately identified by surveyors, thoroughly investigated, and resolved by the entity as quickly as possible. In addition, noncompliance cited at IJ is the most serious deficiency type, and carries the most serious sanctions for providers, suppliers, or laboratories (entities). An immediate jeopardy situation is one that is clearly identifiable due to the severity of its harm or likelihood for serious harm and the immediate need for it to be corrected to avoid further or future seriou
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