Tuesday, December 31, 2019
UPMC Cited for Withholding Records
By Walter F. Roche Jr.
A UPMC facility has been cited for refusing to provide to state surveyors the minutes of meetings of an internal committee established to set and review professional improvement efforts.
Officials of UPMC Somerset told the state Health Department surveyors during a recent visit that they could not review minutes of the committee meetings because they were "peer review protected."
"On November 1, 2019 at approximately 1:00 p.m., multiple requests were made to EMP10 and EMP11, to review the Professional Improvement Committee meeting minutes, in order to evaluate the function and process of the committee. The request was denied," the report states.
In a plan of correction hospital officials said that in the future surveyors will be allowed to review the committee minutes but will not be allowed to take copies from the facility.
The citation marks the second time in recent months that state health surveyors have been rebuffed when they asked for such records. The Guthrie Towanda Memorial Hospital was cited for the same deficiency following a June visit to the facility.
The 99-bed UPMC hospital also was cited for failure to obtain properly executed consent forms from patients undergoing surgical procedures.
In one case an additional surgical procedure was performed that had not been included in the consent form.
In another case a patient undergoing an appendectomy had been anesthetized, but the surgeon canceled the procedure because it had not been approved by the patient's insurance carrier.
UPMC officials did not respond to requests for comment.
Contact: wfroche999@gmail.com
Monday, December 30, 2019
Hospital Cited for "Serious Events"
By Walter F. Roche Jr.
A small rural Pennsylvania hospital has been cited for failing to promptly and properly report serious events involving the care provided to three separate patients.
The recently released report cites the Endless Mountains Health System in Montrose for failing to report serious events to the state Health Department and the Patient Safety Reporting System. Hospital officials told state surveyors that their colleagues didn't think the incidents met the definition of a serious event.
The surveyors were at the hospital to determine whether it complied with the minimum standards for participation in the federally funded Medicare and Medicaid programs.
According to the report a serious event is "an event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient."
Loren Stone, chief executive officer for the health system said, the cases cited by the state Health Department, were, in fact, submitted correctly under the criteria set by the state Patient Safety Authority.
"Endless Mountain Health maintains that they were correctly classified under the Patient Safety Authority guidance and algorithm," he wrote in an email response to questions.
The first case cited in the state report was that of a patient who underwent a CAT scan with a contrast agent. The patient suffered a rash over the entire body due to an allergic reaction to the contrast and had to be treated with Benadryl and other drugs.
The second patient was in the facility for hysterectomy but had to be returned to the operating room due to post-operative bleeding.
The third case involved a patient who was treated for severe pain with a morphine drip. The patient began shaking within 10 minutes of the treatment and was treated with Benadryl and Pepcid.
The hospital filed a plan of correction in which it promised to re-train staff on what constitutes a serious event. The plan also calls for an auditing system to monitor all incidents to ensure they are being properly reported.
The report also faults the hospital for failing to perform annual performance reviews on three certified nurse anesthetists.
In addition a review of records showed staffers failed to perform pain assessments on five patients following the administration of pain medications and before their discharge.
Stone said that the hospital submitted a plan of correction that had been accepted and implemented.
In a final item the state surveyors faulted the hospital for the failure of a member to attend a meeting of the infection control committee. The same finding was included in a prior report on the same facility.
Contact: wfrochejr999@gmail.com
Thursday, December 19, 2019
Antibiotic Delayed, Resident Dies
By Walter F. Roche Jr.
Health care workers at a Tennessee assisted living facility failed to administer a prescribed antibiotic to a resident for four days and she died days later with a massive infection, according to a report from the state Health Department.
The details of the 87-year old woman's illness and subsequent death were included in a 15-page report on Morningside of Paris, an 84 unit assisted living facility. As a result of the Nov. 6 inspection state Health Commissioner Lisa Piercey imposed a freeze on any new admissions to the facility.
Morningside officials did not dispute the state action and said they were working with health officials to correct any deficiencies
The inspection report also questions the handling of the resident, identified only as Resident 12, and her death certificate after she was found unresponsive on Oct. 22.
"Resident 12 was not pronounced deceased by a qualified individual," the report states, noting that the death certificate was not signed until a week after the patient's death, well beyond the 48-hour required limit.
Resident 12 was admitted to a secure unit in the facility on May 3, 2016 and had multiple conditions including schizophrenia, dementia and Alzheimer's disease, records showed.
A review of patient records showed the resident was seen on Oct. 11 for a possible eye infection. A sample collected on that date also showed she had escherichia coli in her urine, which the report noted can result in death if left untreated.
A prescription for an antibiotic was ordered, ampicillin two times a day, the report states. But her first dose of the antibiotic was not administered until 6 p.m. on Oct. 15, when a new prescription was issued by the family nurse practitioner overseeing the resident's care.
Subsequently, the records show, the facility staff learned that the original Oct. 11 prescription had been sent to the wrong address.
When state investigators questioned the nurse practitioner she said she was unaware the drugs had been sent to the wrong address.
The nurse practitioner did say that she had given the patient another antibiotic by injection, although the required documentation was not on file at the facility. The nurse told state surveyors that the documentation was on file at her location.
As for the death certificate, the report questions whether the physician who signed the document had ever even seen or treated the patient.
"There was no documentation Physician 1 had treated, assessed or examined Resident 12 at any time prior to the resident's death," the report states.
Though the death certificate lists sepsis as a contributing cause, it lists medullary failure as the cause of death. The nurse practitioner said she was not aware of the documented cause of death on the death certificate and was "not familiar with that term."
Morningside issued a response to the report stating," We are committed to maintaining a safe and comfortable community," adding that they were working with state health officials to correct and deficiencies.
"In the interim we continue to operate as usual providing outstanding care to facility residents," the statement concluded.
Wednesday, December 18, 2019
Coatesville VA Faulted in Audit
By Walter F. Roche Jr.
An emergency care unit at the Coatesville PA. Veterans Affairs Medical Center was understaffed and out of compliance with minimum VA requirements, according to a report from the VA Inspector General.
The 69-page review issued Wednesday concluded that the lack of staffing and other resources could lead to potentially unsafe situations.
Stating that the facility was required to provide access to appropriate and timely emergency care 24 hours a day, the report found that the facility administrators had failed to obtain a waiver in order to provide round the clock service. Although the leadership was aware of the need for a waiver a preliminary request for a waiver was not submitted until February of this year.
The report noted that no action had been taken on the request.
VA Coatesville officials did not dispute the finding or other deficiencies and submitted a corrective action plan that will gradually reduce the hours of operation for the urgent care unit. Eventually the unit will close at 5 p.m. every day, according to the report.
Other findings include the failure to have two registered nurses on duty 24-hours a day. Citing the fact that the lone remaining nurse from 7 p.m. to 8 a.m. could be called away in an emergency, the report states, "this could result in potentially unsafe situations"in the urgent care center.
The report stated that local VA officials were aware of the requirement for two nurses but did nothing to correct the situation.
The auditors also noted that the emergency unit did not have round-the-clock access to laboratory, pharmacy and radiology services.
"This resulted in delays and inconsistent delivery of care," according to the report.
The auditors also faulted medical center officials for using a VA ambulance to bring patients who experienced a medical emergency while on the facility grounds.
The patients should have been taken to a local emergency room, the report states.
Other deficiencies cited in the report were problems with staff privileging, lack of military sexual trauma training, lack of environmental cleanliness and lack of adequate emergency generator testing.
Contact: wfrochejr999@gmail.com
Saturday, December 14, 2019
PR Touts New Transplant Program
By Walter F. Roche Jr.
Tower Health and its Reading Hospital have launched an extensive public relations campaign to tout their new transplant program, but officials of the health company have refused to answer a series of questions about the program.
Tower announced on Sept. 12 that it would be taking over the transplant program formerly based at the now shuttered Hahnemann University Hospital.
"Thousands of transplants and we're just beginning," proclaims one ongoing Tower television commercial.
In one recent press release the health care firm boasted of the approval of its new transplant institute by regulatory agencies, the United Network for Organ Sharing (UNOS) and the Department of Health.
"The approvals from UNOS and the Department of Health is fantastic news for Tower Health, our patients, and the community," said Clint Matthews, Tower President and CEO, in the Nov.22 press release.
While officials of UNOS confirmed approval of Tower's kidney and liver programs, state Health Department officials did not.
Nate Wardle, a Health Department spokesman, said the agency was informed of Tower Health's plan to initiate a transplant program.
"We will conduct surveys as they go through this process, but the Centers for Medicare and Medicaid Services (CMS) will make the final determination of when the program is approved," Wardle wrote in an email response to questions.
CMS oficials, meanwhile, said they could not comment on any pending applications. Under recent federal rules changes, however, hospitals seeking approval for a transplant program must first seek state approval.
Anne Paschke of UNOS wrote in an email that Reading Hospital has been approved for kidney, living kidney and liver transplantation. She added that their records indicate the program was already in operation.
Among the questions posed to Tower and Reading that went unanswered was whether Tower received bankruptcy court approval to take over the program and whether Tower made any payments into the bankruptcy in return for the program takeover.
Published on November 22, 2019
Tower Health Transplant Institute Receives Regulatory Approvals
West Reading, PA., November 22, 2019 - Tower Health announced today that Tower Health Transplant Institute has received the necessary regulatory approvals from UNOS (United Network for Organ Sharing) and the Department of Health to begin performing transplant surgeries.
"The approvals from UNOS and the Department of Health is fantastic news for Tower Health, our patients, and the community," said Clint Matthews, President and CEO, Tower Health. "We are honored to bring this award-winning team and its renowned physicians and staff to the communities we serve. It is a true display of the relentless pursuit of excellence in all that we do."
The Tower Health Transplant Institute and Center for Liver Diseases includes transplant surgery, hepatology, and nephrology inpatient services at Reading Hospital, selected inpatient services at Chestnut Hill Hospital, and outpatient services at Reading Hospital and in Center City Philadelphia. The team will perform kidney and liver transplants at the Reading Hospital HealthPlex, preserving a leading transplant program for southeastern PA and bringing kidney and liver transplant services to Berks County and its surrounding communities for the first time.
"We are thrilled to have the transplant program, and all that it brings to our patients and communities, be part of Tower Health," said David Reich, MD, Medical Director and Chief Surgeon, Tower Health Transplant Institute. "This is an extraordinary way for us to deliver on our promise of Advancing Health. Transforming Lives."
About Tower Health
With more than 12,000 team members, Tower Health consists of Reading Hospital in West Reading; Brandywine Hospital in Coatesville; Chestnut Hill Hospital in Philadelphia; Jennersville Hospital in West Grove; Phoenixville Hospital in Phoenixville; and Pottstown Hospital in Pottstown. It also includes Reading Hospital Rehabilitation at Wyomissing; Reading Hospital School of Health Sciences in West Reading; home healthcare services provided by Tower Health at Home; and a network of 22 urgent care facilities across the Tower Health service area. Tower Health offers a connected network of 2,000 physicians, specialists and providers across 125 convenient locations. For more information, visit towerhealth.org.
Tower Health Recruits Nationally Recognized Kidney and Liver Transplant Team; Opens Tower Health Transplant Institute
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Published on September 12, 2019
Tower Health Recruits Nationally Recognized Kidney and Liver Transplant Team; Opens Tower Health Transplant Institute
Tower Health announced today that a new Tower Health Transplant Institute has been organized and will become the new home for the nationally recognized kidney and liver transplant program formerly located at Hahnemann University Hospital.
The program's team of renowned surgeons, hepatologists, and nephrologists have joined the Tower Health Medical Group and will provide services in West Reading and Philadelphia. The transplant team surgeons -- who have performed more than 3,000 organ transplants -- will perform kidney and liver transplants at the state-of-the-art Reading Hospital HealthPlex, one of the most technologically advanced surgical facilities in the state. Inpatient services will be provided at Tower Health - Reading Hospital and Tower Health - Chestnut Hill Hospital, with outpatient services at Reading Hospital and in Center City Philadelphia. The Tower Health Transplant Institute will also include the Center for Liver Disease that was part of the Hahnemann program.
"With the unfortunate closure of Hahnemann, our goal was to create a home for this nationally-ranked kidney and liver transplant program so it could continue serving patients in eastern Pennsylvania and surroundings areas," said Clint Matthews, president and CEO of Tower Health. "We are pleased to welcome these ten outstanding surgeons and physicians, along with experienced clinical and support staff. These specialists chose to come to Tower Health because they liked what they saw in our people, our facilities, and our vision."
While at Hahnemann, the Transplant program became the only 5-star-rated kidney transplant program in Pennsylvania and the third best kidney transplant program in the nation as ranked by the Scientific Registry of Transplant Recipients, based on patient survival with a functioning kidney one year after transplant. Tower Health - Reading Hospital, where transplants will take place, is the largest hospital between Philadelphia and Pittsburgh and is recognized nationally for its exceptional clinical quality and safety, advanced technology, and compassionate care.
David J. Reich, MD, Medical Director of the Tower Health Transplant Institute and Professor of Surgery at Drexel University College of Medicine, noted that "along with internationally distinguished hepatologist, Santiago J. Muñoz, MD, and nephrologist, Karthik M. Ranganna, MD, our entire group is delighted to remain a team and to join the preeminent Tower Health system that is setting national standards for healthcare quality and patient satisfaction. We are deeply committed to excellence in clinical care, improving access to transplant services, and to the expanding academic mission of Tower Health." Dr. Muñoz is Medical Director of Liver Transplant and the Center for Liver Disease, Tower Health Transplant Institute and The Donald Berkowitz Professor of Medicine at Drexel University College of Medicine. Dr. Ranganna is Medical Director of Kidney Transplant, Tower Health Transplant Institute and Associate Professor of Medicine at Drexel University College of Medicine.
Within the Transplant Institute, the Center for Liver Disease will provide comprehensive care and leading-edge therapies to manage and treat a variety of liver diseases."We are pleased to have a new home at Tower Health that will allow us to care for our patients with liver disease without interruption," said Dr. Muñoz. "And, we are excited to work with Tower Health on advancing liver disease services in the region."
Pending approval by UNOS (the Unified Network of Organ Sharing), transplants could begin by the end of 2019. Outpatient services, such as patient pre-surgical evaluation and monitoring and transplant follow-up will begin in September. Communications are underway with patients about the new locations for their care and how to ensure uninterrupted care.
"We are thrilled that Tower Health is able to preserve, and will work to grow, one of the best transplant programs in the country," said Mr. Matthews. "The relocation of this program also represents a major expansion of Tower Health's capabilities in meeting the full spectrum of health needs for the communities we serve."
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Thousands of transplants and we're just beginning.
Monday, December 9, 2019
Patient Abused at State Run Home
By Walter F. Roche Jr.
A 73-year-old dementia patient who became combative, was beaten by a state of Pennsylvania employee assigned to care for the him at a state run facility in Franklin County.
The state employee, who was subsequently arrested, slapped the man after he had struck her. Despite pleas from her co-worker to stop, the employee continued to slap the patient on the chest and arms.
Though she stopped momentarily, the employee then slapped the patient two or three more times.
The incident at the South Mountain Restoration Center was described in detail by a state Health Department inspector in a report issued on July 31.
Court records show that the charges against Melinda V. Rutledge were ultimately dismissed by a Franklin County district judge.
"The resident has a right to be free from abuse and neglect," the state inspection report states, adding that the allegation of abuse was substantiated as a result of the investigation. .
The 73-year-old patient, who had impaired vision in addition to deafness, had a history of traumatic brain injury, the report states.
The report on the incident at the 159-bed facility is not the first to show problems with patient care at the facility. Earlier this year state surveyors found that a female patient was the victim of a male patient who sexually abused her. He was found in the female patient's room with his hand in her briefs.
South Mountain describes itself on its web site as a provider of "compassionate, professional quality care" for patients who have "exhausted other alternatives."
According to the state report the July 21 incident began at 10:45 p.m. when two aides went to the male patient's room to provide care.
"Resident 1 (the male patient) was not co-operating and started to become combative," the report states. The resident then struck the aide and she responded by slapping the patient with an open palm
several times on the arm and chest.
"I told her not to hit him and tried to get her to leave the room," a fellow worker told the state surveyors, adding that the employee then struck the patient two or three more times.
She said she then sought help from another employee, but the aide refused to leave the room. Eventually a supervisor was summoned.
One of the other employees told the surveyors that she told the aide that "it was probably not the best to yell at the patient because he did not have his hearing aides on. That worker said she could hear loud slapping and screaming from another patient's room.
Yet another employee reported that she saw red marks on the patient's side following the incident.
In a response to the report, managers of the facility said that by the next day the red marks had "dissipated" and the patient subsequently underwent a psychiatric evaluation.
They also stated that a subsequent investigation showed no other such events and no other reports of patient abuse were discovered.
According to the management response in-service training was provided for staff and steps were taken to avoid future incidents of "caregiver burnout and compassion fatigue."
Employee charged after patient struck in Pa.
SOUTH MOUNTAIN, Pa. — An employee of the South Mountain Restoration Center was charged Tuesday after she allegedly struck a resident, Pennsylvania State Police said.
Melinda Victor Rutledge, 38, of Chambersburg, Pa., was served with a summary harassment/physical contact summons by the office of Magisterial District Judge Kelly Rock.
Police went to the center on South Mountain Road on Sunday at 10:45 p.m. and determined that a staff member struck a resident, identified as a 73-year-old man from Wernersville, Pa.
South Mountain Restoration Center is a 159-bed long-term care facility licensed by the Pennsylvania Department of Health, according to the state’s website.
The center is certified by the Centers for Medicare and Medicaid Services, according to the website.
There are 61 surveys for this facility. Please select a date to view the survey results.
Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
SOUTH MOUNTAIN RESTORATION CTR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on the findings of an Abbreviated Incident survey completed on July 31, 2019, at South Mountain Restoration Center; the facility was found to be not in compliance with the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.
Plan of Correction:
483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
§483.12(a) The facility must-
§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:
Based on clinical record review, facility documentation review and staff interview, it was determined that the facility failed to ensure one of three residents reviewed were free from physical abuse (Resident 1).
Findings include:
Review of Resident 1's on July 29, 2019, at approximately 11:00 AM, revealed diagnoses that included a history of traumatic brain injury (injury to the brain that causes an array of possible cognitive and/or psychomotor deficits), and dementia (irreversible, progressive degenerative disease of the brain that results in decreased contact with reality and difficulty performing activities of daily living).
Review of Resident 1's comprehensive plan of care revealed a care plan wit a focus of, "[Resident 1] is resistive to care at times [related to] Dementia, hearing impairment, and vision impairment," which was initiated on July 8, 2019, and had a goal of, "[Resident 1] will cooperate with care through next review date," which was initiated on July 8 and revised July 12, 2019. Review of the interventions for Resident 1's resistance to care included, "If [Resident 1] resists with [activities of daily living], reassure [Resident 1], leave and return 5-10 minutes later to re-approach."
Review of facility incident investigation report revealed a witness by Nurse Aide (NA) 2, dated July 21, 2019, that stated, "[NA 1] and I went into [Resident 1]'s bedroom to provide care during last rounds at [10:45 PM]. [Resident 1] was not cooperating and started to become combative. The resident struck [NA 1] and after she was struck she slapped the resident with an open palm multiple times on the left arm and chest. I told her not to hit him and tried to get her to leave the room. She then hit the resident 2 or 3 more times on the arm and chest again. I told her to stop and then went and got my coworker who was in the bedroom across the hall. [NA 3] came to the room with me and her and I both tried to get [NA 1] to leave the room, but she wouldn't...After the incident, the supervisor was notified around [11:00 PM] - [11:05 PM]..."
Review of facility witness statement completed by NA 3, dated July 21, 2019, revealed it stated, "Me [NA 3], [NA 1], and [NA 2] were doing last rounds. Start at 10:30 PM as we approached the residents room [NA 2] and [NA 1] went in to and try to put the resident to bed and change him. I [NA 3] went to the next residents room. As I was caring for another resident I could hear [NA 1] yelling at [Resident 1]. When i finish caring for the other resident I left the room and went to [NA 1] and said 'It's probably not the best idea to yell at him," but [NA 1] continued." During a staff interview on July 29, 2019, at approximately 12:20 PM, Nursing Home Administrator revealed that, at the time, NA 1 was heard yelling and it was explained to NA 3 that Resident 1 did not have his hearing aides in at the time. NA 3's statement continued, "I [NA 3] went on to care for other residents and as I was caring for them I could hear loud slapping and screaming coming from [NA 1]. Then [NA 2] came over to the room I was giving care in and asked me to please help him because [NA 1] won't stop yelling and hitting [Resident 1]...As I was trying to calm [Resident 1] down I noticed red hand prints on the chest and left shoulder, so I proceeded to get the nurse [Licensed Practical Nurse 1]."
Review of Licensed Practical Nurse [LPN] 1's witness statement dated July 21, 2019, revealed it stated, "[NA 3] came and notified me that [Resident 1] was having behaviors and needed help. When I walked into [Resident 1's] room I saw a red mark on his left side of his chest."
Review of facility investigation report revealed that the facility investigation of allegation of physical abuse by NA 1 against Resident 1 was found to be substantiated.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1) Management
28 Pa Code 201.29(j) Resident rights
.
Plan of Correction - To be completed: 08/30/2019
1. The red marks associated dissipated the following day. R1 has been seen by Psychiatry for evaluation with recommended medication timing adjustments to improve acceptance of care. R1 meets with his social worker at least weekly for emotional support and encouragement. There have been no other occurrences or events related to abuse for this resident. Residents care plan for emotional distress related to the incident has been updated to reflect weekly visits from the Social Worker to ensure Psychosocial needs being met and improved interventions for staff approach. NA#1 was immediately removed from duty and remains on suspension pending disciplinary action.
2. Current residents on the unit where NA 1 was assigned will have incident reports for all injuries of unknown origin for the last 30 days reviewed to validate that suspected or reported allegations of abuse have been identified and appropriate follow up has been completed. Residents who are capable of verbally communicating will be interviewed by Social Services to validate that there have been no unknown allegations of abuse. Findings of the reviews will be reported to the Quality Assurance and Performance Improvement Committee.
3. In-service training will be completed for nursing staff to include the components of Abuse regulations and accompanying guidelines for these regulatory components. Resources will be provided to all licensed and non-licensed nursing staff in regards to caregiver burn-out and compassion fatigue. All resident grievances are reviewed by the facility's Executive staff to identify any potential issues related to abuse or rights violations and validate that appropriate actions have been taken.
4. The Quality Assurance Director and/or designee will review and audit all grievances as well as incident reports for injuries of unknown origin weekly for 4 weeks and monthly for 3 months to validate that any identified issues related to abuse have been followed up on accordingly. Audits will be reviewed by the QAPI committee to ensure compliance and quality assurance.
483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:
§483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).
§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
§483.12(a) The facility must-
§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:
Based on observation, clinical record review, facility document review, and staff interview, it was determined that the facility failed to ensure one of three residents reviewed were free of physical restraints (Resident 2).
Findings include:
Review of facility document, with subject of, "Use of Restraints, Seclusion, and Exclusion in State Mental Hospitals and the [South Mountain] Restoration Center," revealed section VII. Restraint," defined a restraint as, "Any method of restricting a person's freedom of movement, physical activity, or normal access to his/her body."
Review of Resident 2's clinical record on July 29, 2019, at approximately 11:30 AM, revealed diagnoses of anoxic brain injury (injury of the brain caused by lack of oxygen that can cause functional and cognitive deficits) and dementia (irreversible, progressive degenerative disease of the brain that results in decreased reality contact and daily functioning ability).
During general observation of the third floor unit on July 29, 2019, at approximately 10:30 AM, Resident 2 was observed ambulating independently in the hallway. Upon observation of Resident 2 it was revealed that Resident 2 had a one-piece suit on that covered Resident 2 from mid-thigh to the neck, and down to mid biceps. Observations of the one-piece suit revaluated an opening in the back of the one-piece suit.
Review of Resident 2's comprehensive plan of care revealed a care plan with a focus of, "Resident 2 has an [activities of daily living] self-care performance deficit," initiated on February 11, 2015 and last revised on June 23, 2017. Review of the interventions for the aforementioned care plan revealed an intervention of, "[Resident 2] wears one piece jumpsuit open in back due to history of frequently exposing himself," which was initiated on February 11, 2015, and last revised on July 23, 2017.
During a staff interview on July 29, 2019, at approximately 12:30 PM, Nursing Home Administrator revealed that Resident 2 is not able to easily remove the one-piece suit.
Review of Resident 2's physician orders revealed no order for the one-piece suit. Review of Resident 2's clinical record revealed no restraint assessment, and no care plan for the one-piece suit.
During a staff interview on July 29, 2019, at approximately 2:30 PM, Nursing Home Administrator revealed that Resident 2's one-piece suit was considered a safety device. During the interview, Nursing Home Administrator revealed that safety devices were not considered restraints.
28 Pa Code 211.8(c)(d)(e)(f) Use of restraints
28 Pa Code 211.12(d)(5) Nursing services
Plan of Correction - To be completed: 08/30/2019
1. The staff began a trial with traditional clothing for Resident #2 immediately following the survey. Staff are working to identify style of clothing best suited to resident's need given activity level and safety awareness.. Resident #2's Plan of Care has been updated to reflect that he no longer wears one piece suits and utilizes typical clothing. The facility has developed a Procedure for the use of one-piece suit for the purpose of health, safety or dignity of residents or peers and the nursing staff and physicians will be educated on this procedure. If R2 presents with the potential need for one piece suits, the procedure will be followed.
2. There are no other residents in this facility using a one piece suit at this time. If a resident presents with the potential need in the future, the facility procedure will be followed.
3. In-service training will be completed with nursing staff and facility staff physicians regarding One Piece Suit Procedure and in relation to the F604 tag, requirements of trial use when implementing, observations, need for physician's order, and proper Care Planning of use. Training completion will be reported to the Quality Assurance and Performance Improvement Committee.
4. The Quality Assurance Director and/or designee will review and monitor all residents in the facility for use on One Piece Suits for a period of 6 months. This review will include proper implementation of the procedures, proper documentation of the trial and implementation of physician order, and communication of need with the staff. Any new implementations of One Piece Suits will be reported to the Executive Staff via the Executive Staff Morning Report. Monitoring will be reported monthly to the QAPI Committee.
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Tuesday, April 30, 2019
PA Run Home Failed to Protect Patients
By Walter F. Roche Jr.
A Pennsylvania run nursing home has been cited by one of its own agencies for failing to meet federal health care standards including leaving female residents subject to sexual abuse by a male resident, whose behavior could not be controlled.
In a lengthy report issued by the state Health Department, the South Mountain Restoration Center in rural Franklin County, was also faulted for failing to take steps to prevent vulnerable residents from repeated falls, falls resulting in fractures and other injuries.
The report was based on an inspection conducted earlier this year to determine the facilities compliance with minimum standards for the federally funded Medicare and Medicaid programs. The 159-bed facility is licensed as a nursing home and bills itself as a provider of "compassionate, professional quality care" for patients who have "exhausted other alternatives."
According to the state web site for the center, its patients include former residents of state centers and correctional institutions.
Based on a review of patient records and interviews with patients and employees, surveyors from the state Health Department listed multiple examples of the failure to meet minimum standards in categories ranging from infection control to food handling and maintaining proper individual patient records. The facility was cite for similar deficiencies in the past but failed to implement promised corrective action plans filed in response to those prior citations.
The state Department of Human Services did not respond to a request for comment on the report. The facility did file a corrective action plan in which it promised to make needed corrections.
One male resident, was the focus of several citations in the new report, including touching the breast of one patient and placing his hands in the underwear of another.
The facility "failed to ensure patients were free of non-consensual sexual contact," the report states.
In mid-May the male patient was found in the room of a female patient with his hand in her briefs.
He was asked to leave immediately, according to the report.
Later that same month he was cited again for touching the breast of another female.
The male patient, the report concludes "did not receive adequate interventions to prevent him from inappropriately touching female patients."
In a separate incident with another male resident, a staffer was cited for slapping the patient with a wet facecloth after he was observed with his genitals exposed. The aide had taken the male patient into a woman's room which was in use by a female patient.
The surveyors review of records showed that steps were not taken to prevent additional falls by patients who were considered at risk for falls. And even when falls occurred facility personnel failed to investigate the cause.
In addition in some cases patient records failed to include details of the fall and resulting injuries.
The 2019 report states that South Mountain failed to ensure that effective infection control plans ere in effect. Residents who had tested positive for the flu were observed wandering around without protective masks.
Staffers, according to the report, failed to follow a doctor's orders for a patient on a feeding tube and, in one case, wrongly recorded the amount of nutrient the patient had received.
Still other deficiencies included failure to investigate a patient's charge of abuse and placing an in-dwelling catheter in a patient without a physician's order.
Contact:wfrochejr999@gmail.com
Posted by meningitis-etc.blogspot.com at 6:31 PM
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A 73-year-old dementia patient who became combative, was beaten by a state of Pennsylvania employee assigned to care for the him at a state run facility in Franklin County.
The state employee, who was subsequently arrested, slapped the man after he had struck her. Despite pleas from her co-worker to stop, the employee continued to slap the patient on the chest and arms.
Though she stopped momentarily, the employee then slapped the patient two or three more times.
The incident at the South Mountain Restoration Center was described in detail by a state Health Department inspector in a report issued on July 31.
Court records show that the charges against Melinda V. Rutledge were ultimately dismissed by a Franklin County district judge.
"The resident has a right to be free from abuse and neglect," the state inspection report states, adding that the allegation of abuse was substantiated as a result of the investigation. .
The 73-year-old patient, who had impaired vision in addition to deafness, had a history of traumatic brain injury, the report states.
The report on the incident at the 159-bed facility is not the first to show problems with patient care at the facility. Earlier this year state surveyors found that a female patient was the victim of a male patient who sexually abused her. He was found in the female patient's room with his hand in her briefs.
South Mountain describes itself on its web site as a provider of "compassionate, professional quality care" for patients who have "exhausted other alternatives."
According to the state report the July 21 incident began at 10:45 p.m. when two aides went to the male patient's room to provide care.
"Resident 1 (the male patient) was not co-operating and started to become combative," the report states. The resident then struck the aide and she responded by slapping the patient with an open palm
several times on the arm and chest.
"I told her not to hit him and tried to get her to leave the room," a fellow worker told the state surveyors, adding that the employee then struck the patient two or three more times.
She said she then sought help from another employee, but the aide refused to leave the room. Eventually a supervisor was summoned.
One of the other employees told the surveyors that she told the aide that "it was probably not the best to yell at the patient because he did not have his hearing aides on. That worker said she could hear loud slapping and screaming from another patient's room.
Yet another employee reported that she saw red marks on the patient's side following the incident.
In a response to the report, managers of the facility said that by the next day the red marks had "dissipated" and the patient subsequently underwent a psychiatric evaluation.
They also stated that a subsequent investigation showed no other such events and no other reports of patient abuse were discovered.
According to the management response in-service training was provided for staff and steps were taken to avoid future incidents of "caregiver burnout and compassion fatigue."
Employee charged after patient struck in Pa.
SOUTH MOUNTAIN, Pa. — An employee of the South Mountain Restoration Center was charged Tuesday after she allegedly struck a resident, Pennsylvania State Police said.
Melinda Victor Rutledge, 38, of Chambersburg, Pa., was served with a summary harassment/physical contact summons by the office of Magisterial District Judge Kelly Rock.
Police went to the center on South Mountain Road on Sunday at 10:45 p.m. and determined that a staff member struck a resident, identified as a 73-year-old man from Wernersville, Pa.
South Mountain Restoration Center is a 159-bed long-term care facility licensed by the Pennsylvania Department of Health, according to the state’s website.
The center is certified by the Centers for Medicare and Medicaid Services, according to the website.
There are 61 surveys for this facility. Please select a date to view the survey results.
Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
SOUTH MOUNTAIN RESTORATION CTR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on the findings of an Abbreviated Incident survey completed on July 31, 2019, at South Mountain Restoration Center; the facility was found to be not in compliance with the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.
Plan of Correction:
483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
§483.12(a) The facility must-
§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:
Based on clinical record review, facility documentation review and staff interview, it was determined that the facility failed to ensure one of three residents reviewed were free from physical abuse (Resident 1).
Findings include:
Review of Resident 1's on July 29, 2019, at approximately 11:00 AM, revealed diagnoses that included a history of traumatic brain injury (injury to the brain that causes an array of possible cognitive and/or psychomotor deficits), and dementia (irreversible, progressive degenerative disease of the brain that results in decreased contact with reality and difficulty performing activities of daily living).
Review of Resident 1's comprehensive plan of care revealed a care plan wit a focus of, "[Resident 1] is resistive to care at times [related to] Dementia, hearing impairment, and vision impairment," which was initiated on July 8, 2019, and had a goal of, "[Resident 1] will cooperate with care through next review date," which was initiated on July 8 and revised July 12, 2019. Review of the interventions for Resident 1's resistance to care included, "If [Resident 1] resists with [activities of daily living], reassure [Resident 1], leave and return 5-10 minutes later to re-approach."
Review of facility incident investigation report revealed a witness by Nurse Aide (NA) 2, dated July 21, 2019, that stated, "[NA 1] and I went into [Resident 1]'s bedroom to provide care during last rounds at [10:45 PM]. [Resident 1] was not cooperating and started to become combative. The resident struck [NA 1] and after she was struck she slapped the resident with an open palm multiple times on the left arm and chest. I told her not to hit him and tried to get her to leave the room. She then hit the resident 2 or 3 more times on the arm and chest again. I told her to stop and then went and got my coworker who was in the bedroom across the hall. [NA 3] came to the room with me and her and I both tried to get [NA 1] to leave the room, but she wouldn't...After the incident, the supervisor was notified around [11:00 PM] - [11:05 PM]..."
Review of facility witness statement completed by NA 3, dated July 21, 2019, revealed it stated, "Me [NA 3], [NA 1], and [NA 2] were doing last rounds. Start at 10:30 PM as we approached the residents room [NA 2] and [NA 1] went in to and try to put the resident to bed and change him. I [NA 3] went to the next residents room. As I was caring for another resident I could hear [NA 1] yelling at [Resident 1]. When i finish caring for the other resident I left the room and went to [NA 1] and said 'It's probably not the best idea to yell at him," but [NA 1] continued." During a staff interview on July 29, 2019, at approximately 12:20 PM, Nursing Home Administrator revealed that, at the time, NA 1 was heard yelling and it was explained to NA 3 that Resident 1 did not have his hearing aides in at the time. NA 3's statement continued, "I [NA 3] went on to care for other residents and as I was caring for them I could hear loud slapping and screaming coming from [NA 1]. Then [NA 2] came over to the room I was giving care in and asked me to please help him because [NA 1] won't stop yelling and hitting [Resident 1]...As I was trying to calm [Resident 1] down I noticed red hand prints on the chest and left shoulder, so I proceeded to get the nurse [Licensed Practical Nurse 1]."
Review of Licensed Practical Nurse [LPN] 1's witness statement dated July 21, 2019, revealed it stated, "[NA 3] came and notified me that [Resident 1] was having behaviors and needed help. When I walked into [Resident 1's] room I saw a red mark on his left side of his chest."
Review of facility investigation report revealed that the facility investigation of allegation of physical abuse by NA 1 against Resident 1 was found to be substantiated.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1) Management
28 Pa Code 201.29(j) Resident rights
.
Plan of Correction - To be completed: 08/30/2019
1. The red marks associated dissipated the following day. R1 has been seen by Psychiatry for evaluation with recommended medication timing adjustments to improve acceptance of care. R1 meets with his social worker at least weekly for emotional support and encouragement. There have been no other occurrences or events related to abuse for this resident. Residents care plan for emotional distress related to the incident has been updated to reflect weekly visits from the Social Worker to ensure Psychosocial needs being met and improved interventions for staff approach. NA#1 was immediately removed from duty and remains on suspension pending disciplinary action.
2. Current residents on the unit where NA 1 was assigned will have incident reports for all injuries of unknown origin for the last 30 days reviewed to validate that suspected or reported allegations of abuse have been identified and appropriate follow up has been completed. Residents who are capable of verbally communicating will be interviewed by Social Services to validate that there have been no unknown allegations of abuse. Findings of the reviews will be reported to the Quality Assurance and Performance Improvement Committee.
3. In-service training will be completed for nursing staff to include the components of Abuse regulations and accompanying guidelines for these regulatory components. Resources will be provided to all licensed and non-licensed nursing staff in regards to caregiver burn-out and compassion fatigue. All resident grievances are reviewed by the facility's Executive staff to identify any potential issues related to abuse or rights violations and validate that appropriate actions have been taken.
4. The Quality Assurance Director and/or designee will review and audit all grievances as well as incident reports for injuries of unknown origin weekly for 4 weeks and monthly for 3 months to validate that any identified issues related to abuse have been followed up on accordingly. Audits will be reviewed by the QAPI committee to ensure compliance and quality assurance.
483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:
§483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).
§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
§483.12(a) The facility must-
§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:
Based on observation, clinical record review, facility document review, and staff interview, it was determined that the facility failed to ensure one of three residents reviewed were free of physical restraints (Resident 2).
Findings include:
Review of facility document, with subject of, "Use of Restraints, Seclusion, and Exclusion in State Mental Hospitals and the [South Mountain] Restoration Center," revealed section VII. Restraint," defined a restraint as, "Any method of restricting a person's freedom of movement, physical activity, or normal access to his/her body."
Review of Resident 2's clinical record on July 29, 2019, at approximately 11:30 AM, revealed diagnoses of anoxic brain injury (injury of the brain caused by lack of oxygen that can cause functional and cognitive deficits) and dementia (irreversible, progressive degenerative disease of the brain that results in decreased reality contact and daily functioning ability).
During general observation of the third floor unit on July 29, 2019, at approximately 10:30 AM, Resident 2 was observed ambulating independently in the hallway. Upon observation of Resident 2 it was revealed that Resident 2 had a one-piece suit on that covered Resident 2 from mid-thigh to the neck, and down to mid biceps. Observations of the one-piece suit revaluated an opening in the back of the one-piece suit.
Review of Resident 2's comprehensive plan of care revealed a care plan with a focus of, "Resident 2 has an [activities of daily living] self-care performance deficit," initiated on February 11, 2015 and last revised on June 23, 2017. Review of the interventions for the aforementioned care plan revealed an intervention of, "[Resident 2] wears one piece jumpsuit open in back due to history of frequently exposing himself," which was initiated on February 11, 2015, and last revised on July 23, 2017.
During a staff interview on July 29, 2019, at approximately 12:30 PM, Nursing Home Administrator revealed that Resident 2 is not able to easily remove the one-piece suit.
Review of Resident 2's physician orders revealed no order for the one-piece suit. Review of Resident 2's clinical record revealed no restraint assessment, and no care plan for the one-piece suit.
During a staff interview on July 29, 2019, at approximately 2:30 PM, Nursing Home Administrator revealed that Resident 2's one-piece suit was considered a safety device. During the interview, Nursing Home Administrator revealed that safety devices were not considered restraints.
28 Pa Code 211.8(c)(d)(e)(f) Use of restraints
28 Pa Code 211.12(d)(5) Nursing services
Plan of Correction - To be completed: 08/30/2019
1. The staff began a trial with traditional clothing for Resident #2 immediately following the survey. Staff are working to identify style of clothing best suited to resident's need given activity level and safety awareness.. Resident #2's Plan of Care has been updated to reflect that he no longer wears one piece suits and utilizes typical clothing. The facility has developed a Procedure for the use of one-piece suit for the purpose of health, safety or dignity of residents or peers and the nursing staff and physicians will be educated on this procedure. If R2 presents with the potential need for one piece suits, the procedure will be followed.
2. There are no other residents in this facility using a one piece suit at this time. If a resident presents with the potential need in the future, the facility procedure will be followed.
3. In-service training will be completed with nursing staff and facility staff physicians regarding One Piece Suit Procedure and in relation to the F604 tag, requirements of trial use when implementing, observations, need for physician's order, and proper Care Planning of use. Training completion will be reported to the Quality Assurance and Performance Improvement Committee.
4. The Quality Assurance Director and/or designee will review and monitor all residents in the facility for use on One Piece Suits for a period of 6 months. This review will include proper implementation of the procedures, proper documentation of the trial and implementation of physician order, and communication of need with the staff. Any new implementations of One Piece Suits will be reported to the Executive Staff via the Executive Staff Morning Report. Monitoring will be reported monthly to the QAPI Committee.
______
Tuesday, April 30, 2019
PA Run Home Failed to Protect Patients
By Walter F. Roche Jr.
A Pennsylvania run nursing home has been cited by one of its own agencies for failing to meet federal health care standards including leaving female residents subject to sexual abuse by a male resident, whose behavior could not be controlled.
In a lengthy report issued by the state Health Department, the South Mountain Restoration Center in rural Franklin County, was also faulted for failing to take steps to prevent vulnerable residents from repeated falls, falls resulting in fractures and other injuries.
The report was based on an inspection conducted earlier this year to determine the facilities compliance with minimum standards for the federally funded Medicare and Medicaid programs. The 159-bed facility is licensed as a nursing home and bills itself as a provider of "compassionate, professional quality care" for patients who have "exhausted other alternatives."
According to the state web site for the center, its patients include former residents of state centers and correctional institutions.
Based on a review of patient records and interviews with patients and employees, surveyors from the state Health Department listed multiple examples of the failure to meet minimum standards in categories ranging from infection control to food handling and maintaining proper individual patient records. The facility was cite for similar deficiencies in the past but failed to implement promised corrective action plans filed in response to those prior citations.
The state Department of Human Services did not respond to a request for comment on the report. The facility did file a corrective action plan in which it promised to make needed corrections.
One male resident, was the focus of several citations in the new report, including touching the breast of one patient and placing his hands in the underwear of another.
The facility "failed to ensure patients were free of non-consensual sexual contact," the report states.
In mid-May the male patient was found in the room of a female patient with his hand in her briefs.
He was asked to leave immediately, according to the report.
Later that same month he was cited again for touching the breast of another female.
The male patient, the report concludes "did not receive adequate interventions to prevent him from inappropriately touching female patients."
In a separate incident with another male resident, a staffer was cited for slapping the patient with a wet facecloth after he was observed with his genitals exposed. The aide had taken the male patient into a woman's room which was in use by a female patient.
The surveyors review of records showed that steps were not taken to prevent additional falls by patients who were considered at risk for falls. And even when falls occurred facility personnel failed to investigate the cause.
In addition in some cases patient records failed to include details of the fall and resulting injuries.
The 2019 report states that South Mountain failed to ensure that effective infection control plans ere in effect. Residents who had tested positive for the flu were observed wandering around without protective masks.
Staffers, according to the report, failed to follow a doctor's orders for a patient on a feeding tube and, in one case, wrongly recorded the amount of nutrient the patient had received.
Still other deficiencies included failure to investigate a patient's charge of abuse and placing an in-dwelling catheter in a patient without a physician's order.
Contact:wfrochejr999@gmail.com
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Tuesday, December 3, 2019
Honesdale Hospital Fails Inspection
By Walter F. Roche Jr.
Multiple deficiencies, including overuse of restraints on a child, were uncovered in a recent state Health Department review of a Wayne County 114-bed hospital.
The Sept. 27 inspection report on the Wayne Memorial Hospital concluded that the facility failed to meet the minimum requirements for participation in the federally funded Medicare and Medicaid programs.
In addition to the misuse of restraints the surveyors, during a three day site visit, found that hospital failed to obtain proper informed consent in nine of 52 patient records reviewed.
On the restraint issue, state surveyors cited the case of a 13-year-old child who was suicidal and aggressive. Though hospital policy limited juvenile restraint use to two hours, the unnamed patient was kept in restraints on Sept. 22 for four hours in the emergency department.
The informed consent records reviewed during the inspection showed a variety of omissions. Nine of 52 records lacked witness signatures or the time the consent was obtained.
The inspectors found that crash carts had not undergone daily inspections 17 times over a two month period.
More than a dozen physicians at the facility frequently failed to complete patient records within 30 days of discharge.
Other deficiencies included failure to maintain an accurate inventory of controlled substances and failure to properly re-credential seven staffers.
The report cites multiple sanitation issues including dirt, dust and dried food debris in food preparation areas and dust and debris in patient rooms "considered clean and ready for patient admission."
Contact: wfrochejr999@gmail.com
Monday, December 2, 2019
Geisinger Facility Failed Medicare Certification
By Walter F. Roche Jr.
Multiple deficiencies were observed when Pennsylvania health surveyors conducted a Medicare/Medicaid re-certification survey of a Columbia County hospital.
The survey findings on the 76-bed Geisinger-Bloomsburg Hospital were detailed in a report dated Oct. 11 and made public last week. The deficiencies range from failure to properly complete pre-operative exams to failure to maintain one-to-one observation on a patient deemed to be a danger to self.
The surveyors observed hospital personnel examining patients prior to surgery without listening to the heart and lungs. In some cases they reported staffers failed to get complete medical histories
A review of supplies in the obstetrics department showed that sexual assault examination kits were outdated by a year.
"The room had no acceptable sexual assault kits available for immediate use," the report states.
In another finding the report said records showed a failure to perform a mandated review of available equipment.
The inspectors found that in at least two cases the hospital failed to inform the area organ procurement agency of patient deaths.
The surveyors also observed an employee in an operating room without proper attire.
Finally the surveyors cited the hospital for failure to follow established procedures for the use of pain medications. Patient pain assessments both before and after the administration of the pain medication were not always performed.
"The facility was not in compliance" with requirements for participation in the Medicare and Medicaid programs, the report states.
Facility officials filed a plan of correction in which they said equipment and other deficiencies would be corrected and employees would be given re-education programs and audits would be performed to ensure compliance.
Hospital officials did not respond to questions about the state report.
Contact: wfrochejr999@gmail.com
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