Pediatric Hospital Cited for Multiple Lapses

By Walter F. Roche Jr.

A Philadelphia pediatric hospital failed to report 184 patient safety issues to state officials as required and also failed to timely inform patients' families of adverse events affecting their children.
The multiple lapses were listed in a report on the 189-bed Saint Christopher's Hospital for Children recently made public by the state Health Department.
Officials of the hospital, which recently underwent a change of ownership, also failed to file a plan of correction in response to the critical state report. Hospital officials did not respond to requests for comment.
St. Christopher's was recently sold out of bankruptcy for $50 million to Tower Health and Drexel University.
In yet another finding, state surveyors found that the hospital allowed a staffer, whose license had expired, to treat 11 cardiac cases. The staffer's license expired on Dec. 21, 2018 and was not renewed until Aug. 2, 2019. The report does not disclose what kind of license was involved.
The state also found major lapses in mandated quality improvement plans and a failure to conduct focused reviews of adverse events.
The hospital failed to report nine cases in which patients suffered pressure injuries within the required 24-hour time limit, according to the report.
The facility failed to report the 184 patient safety issues to the state Patient Safety Authority. In addition the hospital failed to inform families in three cases of a serious event within 24 hours of its occurrence.
When state surveyors questioned a hospital employee about the multiple issues, they were told that the hospital was in bankruptcy and there was not enough money.
Contact: wfrochejr999@gmail.com

York Patient Dies Despite Monitor Alarm

By Walter F. Roche Jr

An inpatient at a York hospital died without medical intervention even though an alarmed monitor was recording the precipitous decline of vital signs, according to a report issued by the state Health Department.
The facility "failed to intervene and provide care for a patient with declining oxygen and brachycardia leading to death," the report on the WellSpan York Hospital states.
The report dated Dec. 26 came just three days after another Health Department report found that patients arriving at the same hospital's emergency room in October waited well over an hour before having their care transferred from emergency medical responders to hospital staff.
State surveyors said the hospital failed to have adequate licensed registered nurses and other personnel "to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient."
Increased scrutiny of the York hospital follows an August incident in which a patient in the facility's emergency room went unnoticed until he was finally found dead more than three hours after his arrival.
A WellSpan Health spokesman said today that the hospital has implemented enhanced response procedures.
"We have made key staffing and process improvements to ensure the quick, efficient transfer of patients from emergency medical staff to hospital employees," Ryan Coyle wrote in an email response to questions.
According to the Dec. 26 report hospital officials told the state surveyors that the staffer watching the monitors was unable to respond immediately because of a lack of nursing staff.
State surveyors reviewing the hospital's records, found that the initial alarm came at 1:26 p.m.on Oct. 17, when the monitor recorded that the patient's oxygen saturation level had dropped to 77 percent with a pulse of 109 beats per minute.
By 1:45 p.m. the oxygen saturation had dipped to 33 percent and a pulse of 75, the report states.
"The following three minutes show no oxygen reading with a final heart rate of 28 beats per minute," the report continues.
"No evidence exists that staff responded to contact nursing personnel," the report states.
The report notes that corresponding electrocardiogram tracings of the same time period "reveals decreasing cardiac activity until cardiac activity ceased."
"No information was given to care providers about the alarming oxygen saturation or heart rates," the surveyors reported.
The surveyors reported that eventually a nurse's aide went to the patient's room but was apparently unaware of the patient's alarming decline as there were no monitors in the patient's room.
"It was determined that the facility staff failed to utilize good management techniques to avoid the personal discomfort of the patient," the report concludes.
The hospital also was faulted for not including the incident in the patient's personal health record.
In a plan of correction filed with the state York hospital officials said that policies were revised to ensure those monitoring telemetry devices alerted nursing staff to alarming readings. The plan also calls for an auditing system to ensure compliance by staff. The plan also includes education and retraining for staff.
Coyle said the plan of correction was accepted by the state.
The incident is the second in recent months at the 596-bed hospital in which a patient expired without medical intervention.
In an October report, state surveyors found that a patient expired in the hospital's emergency room without even being seen by staffers over a several hour period. Video monitors showed staffers passing within one or two feet of the patient for well over an hour.
State surveyors were told that staff assumed the patient had left when he failed to respond when his name was called. The incident occurred on Aug. 17. The patient was brought to the hospital at 9:59 a.m.. He was finally pronounced dead at 1:31 p.m.
In the state's Dec. 23 review of cases brought by ambulance to York's emergency room in October, four of seven patients reviewed waited for periods ranging from 51 minutes to 73 minutes.
The report refers to a process called "parking" in which emergency room patients are left sitting extended periods while waiting for assessment and needed care.
"The nursing service must have adequate numbers of licensed registered nurses, licensed practical nurses and other personnel to provide nursing care to all patients as needed," the report states.
In a plan of correction filed by Wellspan York, the hospital reported that it had hired two additional nurse recruiters and was offering signing bonuses and providing other incentives to bring on additional staff.

Hospital Failed to Act on Impaired Surgeon

By Walter F. Roche Jr.

A western Pennsylvania hospital failed to take immediate action when an on-duty surgeon was observed staring into space and had slurred speech, according to a report from the state Health Department.
In a report just made public the state agency said the delayed action by administrators at the 216 bed Penn Highlands- Dubois Medical Center placed patients in jeopardy and violated the facility's own established policies.
A review of hospital records showed several employees had expressed concerns about the surgeon's behavior and strongly suspected drug or alcohol use was the cause.
The record review also showed that at least three scheduled surgical procedures had to be canceled and re-scheduled because the unnamed surgeon never showed up.
"The information you are requesting involves personnel matters; therefore, we cannot share additional information," said Penn Highlands spokeswoman MaryJo Yebernetsky when asked for a comment.
"People in the operating room went to Employee 10 and said the doctor was not acting appropriately," the report states.
Two employees told state inspectors that the operating room leadership "did not follow the policy" for cases of suspected employee impairment.
That policy called for immediate action to report the suspicion to the employee's supervisor or to the human relations department.
"Employee 9 was slurring and staring into space," one employee told state surveyors, who visited the hospital in December.
The three cases of delayed surgery due to the physician's absence occurred in August.
"Aug. 6 surgery cancelled due to doctor not here," the report states.
Another employee told the inspectors the surgeon was "routinely late."
When the Health Department workers confronted one of the managers, the manager said, "I don't think it was brought to my attention. Today was the first day I knew about this."
Another employee told the surveyors,"I didn't feel safe. I thought that Employee 9 was impaired."
The hospital did file a plan of correction in which it said new policies were being adopted and that any canceled surgeries would be reviewed and any doctor who had three surgeries canceled in a three month period would get a warning.
The corrective action plan also calls for staff to be re-educated on the procedures to be followed in a case where an employee was suspected of alcohol or drug abuse.
The state report also faulted the hospital for failing to appoint a manager of surgical services who met the requirements of the job. The manager was an anesthesiologist but the job specifications called for a surgeon to hold the post.

Patient Abuse at PA Vets Home

By Walter F. Roche Jr.

A resident at a Pennsylvania veterans nursing home was subjected to mental abuse, according to a report from the state Department of Health.
The incident occurred at the Hollidaysburg Veterans Center in Blair County, one of six state run nursing facilities for veterans in Pennsylvania. A second veterans home, the Southwestern Veterans Center in Pittsburgh also was cited recently for an incident in which a patient suffered a finger fracture.
According to the Hollidaysburg report, an unnamed employee interacted inappropriately with a male patient who was cognitively impaired.
The nurse's aide prompted the patient to repeat vulgar/sexual statements which then provoked laughter from other unidentified employees.
The incident was reported by a dietary aide, who witnessed it a day earlier. The incident was not immediately reported to the home administrator as required, the report states, adding that the details were verified by another employee.
Noting that employees were instructed to err on the side of reporting if they were unsure of an abuse incident, the state Health Department surveyors noted that it wasn't until four days after the incident when the home administrator was notified.
In a plan of correction filed by the veterans center, officials promised to conduct a re-education program for staffers on the requirements for reporting suspected physical or mental abuse. The patient, according to the surveyors, had no recollection of the incident
The center also was faulted for failing to respond promptly and properly to an incident in which a resident's midline catheter fell out.
Yet another resident had been administered an opioid 32 times in a three month period without a proper assessment of the level of pain the resident was experiencing.
The home's quality improvement team also was criticized for failing to complete compliance audits despite repeated deficiencies.
At the Pittsburgh veterans home surveyors reported that a resident was found to have a bruised finger. A subsequent X-Ray showed the patient had a fractured finger as a result of a fall during a wheelchair to bed transfer.
The certified nursing assistant involved, however, failed to report the incident as required.
In a plan of correction home officials said the nursing assistant was "immediately in-serviced" on fall management practices.
Another resident complained that mail from her daughter had been opened and an herbal supplement contained in the package had been removed.
Center employees said they had opened the package due to concern that it contained unapproved medications.
In a plan of correction home officials said staff would be instructed not to open patient mail and audits would be conducted to ensure compliance.
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Hospital Cited in Patient Escape

By Walter F. Roche Jr.

State health officials declared a state of immediate jeopardy at a Scranton hospital after reviewing records of a patient who had been involuntarily committed but was able to escape from the hospital's intensive care unit on Dec. 10.
A report on the December incident at the Regional Hospital of Scranton concludes that the 186-bed facility failed to follow its own policies and state requirements in its handling of the unnamed male patient.
The report does not indicate what ultimately became of the patient and hospital officials did not respond to a request for comment.
The immediate jeopardy declaration forced the hospital to come up with an immediate remediation plan. The first plan produced by the hospital was rejected, but the second was accepted.
According to the report the patient was brought to the hospital by ambulance on Dec. 8 and was eventually judged by a physician to be severely mentally disabled and in need of treatment.
The patient had pulled out an intravenous tube and demanded to be released. He was eventually in-tubated and place on a respirator.
The records showed that at one point staffers became concerned about the patient's escalating behavior and "the health and safety" of both the staff and the patient himself. The patient was "not making sense." Police were called and stood at the patient's bedside.
The physician who examined the patient concluded that he should be committed to a facility recommended by the county administrator.
The report faults the hospital for failing to perform a suicide assessment on the patient and for failure to implement an emergency "Code White" as the situation worsened. A Code White is declared to deal with a violent or potentially violent individual.
Although a one-on-one monitor was assigned to the patient, he became combative and ran towards a back door.
The hospital's plan of correction calls for a re-education of staff members, revision of some policies relating to the handling of committed patients and a series of audits to ensure staff compliance.
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