Wrong IV Administered at Wilkes Barre Hospital

By Walter F. Roche Jr.

A patient at a Wilkes Barre hospital was given an IV prescribed for another patient and even after the error was uncovered the patient's doctor was not informed.
That was the finding of an August state licensure inspection at the PAM (Post Acute Medical) Specialty Hospital, a 36-bed facility located within the Wilkes Barre General Hospital.
The IV mixup was only one of several medication errors turned up in the five-day inspection of the hospital in early August. And the same facility was cited twice in 2019 for other violations including a lack of adequate staff.
In the recent report one patient had been prescribed a five percent dextrose in a saline solution at a rate of 100 milligrams per hour.
A second patient had been prescribed a 5 percent dextrose solution in water administered at 50 milligrams per hour.
On Nov. 4 of last year at a shift change at 10 p.m. a nurse discovered that the first patient was getting an IV with the second patients's information on it.
Hospital records showed the patient getting the wrong IV had been administered 80 milligrams of wrong IV before it was discovered.
The report states that despite a hospital requirement that serious medication errors had to be reported to the physician of the patient affected, the records showed no documentation that the notification took place.
In addition the error was not recorded in the patient's record.
In another case, the report states that a doctor's order to increase the dosage of a drug was not implemented. And again the patient's doctor was not informed, according to the report.
In the same inspection state surveyors found that a crash cart had three expired vials of sodium chloride.
The hospital filed a plan of correction calling for re-education of staff on the requirements for reporting medication errors "that have harmed or have the potential to harm the patient."
The hospital also implemented a plan to ensure that expired medications were removed from crash carts.
Hospital officials did not respond to questions about the report.
Contact: wfrochejr999@gmail.com

Hospital Failed to Screen for Covid-19

By Walter F. Roche Jr.

A suburban Philadelphia hospital failed to follow state and federal requirements in screening some 91 visitors to the 371-bed facility for coronavirus, according to a report by state Health Department officials.
The report dated Aug. 11 but only made public this week, states that Saint Mary Medical Center "failed to ensure all visitors were actively checked for temperatures and docmented in a log."
A review of hospital records for the first 10 days of August showed that for 91 of 172 visitors there was no documented evidence that these visitors had their temperatures taken."
The facility was not in compliance with state and federal Covid-19 guidelines, the report states.
In a plan of correction filed by the hospital, Saint Mary officials said they implemented an education program for employees on proper screening and maintaining the required log.
The hospital was cited in a separate report for failing to get proper informed consent from another patient. State surveyors were told hospital employees were unable to get a patient signature due to the Covid-19 pandemic.
"The facility failed to follow their policy for obtaining consents during the Covid-19 pandemic," the report states.
In yet another finding state surveyors cited the hospital for giving improper discharge instructions to a patient.
The patient was instructed not to remove nasal packing until the next day when a visit with an eye, ear and throat specialist was scheduled. The patient, however, had no nasal packing.
Hospital officials did not respond to a request for comment.
Contact: wfrochejr999@gmail.com

Hospital Cited for Turning Away ER Patient

By Walter F. Roche Jr.

A Clearfield County hospital has been cited for turning away a clearly distressed patient seeking care in the emergency room.
According to a report from the state Health Department the patient was told by a Penn Highlands Clearfield employee to go home and call for an ambulance. Ultimately an ambulance picked up the patient on the hospital grounds and then brought the patient to the emergency room.
In the report state Health Department surveyors cited a federal law, the Emergency Medical Treatment and Labor Act, which requires that a hospital with an emergency room must provide a prompt examination and treatment.
The hospital "failed to ensure that a medical screening examination was provided for one patient who presented to the emergency room," the report states.
The incident occurred on May 18 at 12:42 p.m. when the patient, accompanied by a relative, arrived at the hospital in the front passenger seat. The state surveyors reviewed hospital records and also viewed videotapes showing the patient's arrival.
"The patient was noted to be extremely upset, embarassed and crying," the report states, adding that the patient, who had suffered a fall, came to the hospital under a doctor's instructions.
"The patient was told by an employee they could not help because the patient was a fall risk," the report states.
Officials of the 50-bed hospital did not respond to requests for comment.
In addition to failing to make a required assessment of the patient, hospital employees failed to enter the patient's first visit into the emergency department log.
"The patient should have been entered into the log and then formally transferred," the report states.
The hospital filed a plan of correction calling for retraining of emergency room employees on the requirements of the federal law and also the handling of "patients of size."
The report also cites the hospital for failure to maintain the required physician-on-call list.
Contact: wfrochejr999@gmail.com

Phila VA Official Indicted for Bribery

By Walter F. Roche Jr.

The head of environmental services at the Veterans Administration Hospital in Philadelphia was indicted today for solicting bribes from two Florida contractors to steer contracts to their firms.
In an 11-page indictment filed in U.S. District Court in Philadelphia Ralph Johnson, the head of environmental services at the Veterans Administration Medical Center, was charged with three counts of soliciting bribes.
In an affidavit filed in the case an FBI agent said that Earron and Carlicha Starks paid over $100,000 in bribes to Johnson who then steered a series of contracts to two Florida firms controled by the Starks.
In one instance Johnson steered an $84,000 tree trimming and removal contract to the Starks in return for a $3,000 payment. According to the indictment the work under the contract was actually performed by a subcontractor for $4,000.
According to the 12-page affidavit from Special Agent Brett Nelson Johnson steered conracts worth more than $2 milllion to two Starks companies.
Some of those contracts were awarded under a program setting aside contracts for businesses controlled by service disabled veterans, but the Stark companies were "not legitimate" service disabled businesses, the affidavit states.
According to the affidavit the Starks were wearing wires during two of their meetings with Johnson, one in Philadelphia on June 13, 2019 and the other on Aug. 14, 2019 at an Orlando hotel.
The Starks "traveled regularly to Philadelphia" to pay over $100,000 in bribes to Johnson.
Records show the Starks already have entered guilty pleas in Florida to a single count of conspiracy to commit health care fraud. They have yet to be sentenced.
If convicted, Johnson faces a possible sentence of 45 years imprisonment, 3 years supervised release, and up to a $750,000 fine.
Contact: wfrochejr999@gmail.com.

PA Hospital Faulted in Drowning

By Walter F. Roche Jr.

Staff at a Pennsylvania psychiatric hospital didn't notice for 20 minutes that a patient had not returned with 11 others from a pond located on the facility grounds.
That was one of the findings of state health inspectors investigating the July 24 drowning of a 46-year-old woman at the Wellspan Philhaven Hospital in Mt. Gretna.
The report made publc this week concludes that the hospital was out of compliance with state and federal licensing requirements because it failed to provide care in a safe setting. The report cites "substantial deficient practices related to the on-site investigation for a patient death."
According to the report the unnamed woman had previously told staffers that she wanted to kill herself.
"I wish I just had a big knife and could just cut myself and be done. I want to be put in a place and let go until I die," the patient was quoted as saying.
A review of records and interviews showed that the victim was one of 12 brought to a pond on the grounds of the hospital, but when the group was brought back to the living quarters just before 5 p.m., no one noticed that only 11 returned.
"The staff failed to notice that the patient did not return to the unit," the report states, noting that hospital protocols required staff to accompany clients on all off-unit activities.
After her absence was noted staff pulled her body from the pond and attempted resuscitation but the effort failed.
The state surveyors also noted that the hospital staff had never addressed the patient's swallowing issues.
She had told a hospital worker, I cannot eat or drink. I am very weak."
Although the hospital did install a temporary fence around the pond and promised to re-educate staff on patient safety checks, an approved plan of correction was not filed.
Contact: wfrochejr999@gmail.com

PA Hospital Turned Patient Away

By Walter F. Roche Jr.

A Pennsylvania hospital has been charged with violating a federal law when it turned away a patient who had arrived in an ambulance with a police escort.
In a report just made public by the state Health Department, state surveyors found that a nursing supervisor at Washington Health System Greene told police to take a behavioral patient who had displayed violent behavior to another unnamed hospital "that was better staffed and equipped to manage patients with behavioral issues."
The 23-bed facility is the only acute care hospital in Greene County in the far southwest corner of the state. The hospital boasts of having 24-hour emergency care. Hospital officials did not respond to a request for comment.
The incident occurred on April 23 and the investigation initiated April 28, but the report was not issued till July 20, apparently due to Covid-19 pandemic.
The report cites the federal Emergency Medical Treatment and Active Labor Act which bars hospitals from turning away patients before a medical examination and assessment are performed.
"The patient did not have a medical screening prior to transfer," the report states, adding that employees confirmed that the facility failed to provide an appropriate medical screening examination."
The report notes that the hospital self reported the "non-compliance" and "was found in compliance at the time of the survey."
Despite reporting the incident, the hospital failed to file an approved Plan of Correction.
Contact: wfrochejr999@gmail.com

Troubled PA Vet Home Cited Again

By Walter F. Roche Jr.

The state run nursing home for veterans where 42 residents died in a Covid 19 outbreak has been cited for failing to properly monitor a patient who had told staffers he simply wanted to die.
A report on the Southeastern Veterans Center in Spring City concluded that the facility "failed to adequately monitor one of one residents reviewed who had expressed a death wish and had a history of suicidal ideation."
The 238-bed facility in suburban Philadelphia has been the subject of prior highly critical inspection reports based on the mishandling of the deadly Spring coronavirus outbreak.
The new report, dated July 23, states that the unnamed male patient had been re-admitted to the veterans center from a local hospital suffering from dementia and coronary artery disease.
The patient had "a documented history of expressing a desire to hurt himself," the report states, adding that a staff member reported that the patient had just stated a desire to hurt himself.
A review of facility records by state surveyors showed no documentary evidence that many of the 15 minute checks on the suicidal patient which had been ordered were actually performed.
No 15 minute checks were documented from 7:45 a.m. to 2:45 p.m. on July 12. The same was true from 3 p.m. to 11:45 p.m.on July 13. And on July 14 and July 15 the 15 minute checks were completely undocumented on all three shifts.
The facility administrators filed a plan of correction in which they stated that the patient had been re-evaluated by an outside consultant "and new orders were received. He has no suicidal ideations with a formulated plan currently."
The plan also calls for staff re-education on the requirements for a one-to-one watch on a suicidal patient.
The state Health Department surveyors, meanwhile, have made spot checks at the five other state veterans homes and found them in compliance with state and federal requirements for the handling of Covid-19 cases.
One other facility, the Delaware Valley Veterans Center in Philadelphia, has reported 13 Covid-19 deaths.
Contact: wfrochejr999@gmail.com

Scranton Hospital Cited Again

By Walter F. Roche Jr.

A Scranton hospital has been cited for the second time in a month by state Health Department surveyors this time for failing to keep watch on a suicidal patient who was injured in a failed attempt.
In a report made public this week the Regional Hospital of Scranton was faulted in the care of a patient who arrived at the facility on March 7 acknowledged having suicidal thoughts. He also had "a history of cutting arms" and was regarded as a high risk for suicide.
The patient was taken to a bathroom by an employee assigned to provide a one-to-one watch, but once inside the bathroom the patient found a tongue depressor, broke it into pieces and then self inflicted an arm wound requiring two stitches.
"The facility failed to provide continuous observation of a suicidal patient that resulted in the patient lacerating themselves," the report states.
The report also faults the hospital for failing to report the incident within 24-hours as required by a state law.
The surveyors also cited the hospital for failure to eliminate suicide risks including a metal hook on the wall.
In its plan of correction hospital officials said suicidal patients will no longer be brought to bathrooms but provided with "a urinal and/commode. The plan also calls for a staff re-education program on the requirements for a one-to-one watch.
The Scranton facility was cited earlier this month for improperly transferring patients to another facility and failure to provide needed MRI services. An improper transfer also was noted in a prior report.
Contact: wfrochejr999@gmail.com

State Resumes All Hospital Inspections

By Walter F. Roche Jr.

In March of this year, surveyors from the Pennsylvania Health Department visited a Scranton hospital and found multiple violations of state and federal law including the premature discharge of a seriously ill patient.
Nonetheless a report on those findings was not completed and made public until months later. The delay was one of about 65 hospital survey reports put on hold, according to state officials, because of an order from a federal agency, the Centers for Medicare and Medicaid Services.
Nate Wardle, state Health Department spokesman, said the delay from mid-March through July was the result of a CMS directive to limit survey activity and focus on Covid-19 preparations and operations.
He said the order was lifted and state surveyors were authorized to resume normal survey activities on July 3.
Wardle said any backlog has been erased and all survey activities are now ongoing and up to date.
"Any surveys related to complaints which indicated a potential risk to patients, including risk for serious injury, serious harm or death, were not put on hold and did occur with site visits," Wardle said in an email response to questions.
"The hospital surveys that were most impacted were licensure surveys and recertification surveys," Wardle added.
The recently released report on the Regional Hospital of Scranton, however, indicates that violations of state laws and regulations were put on hold for several months.
"The report was held due to a directive from CMS," the July 17 report states, adding that the report was triggered by two complaints.
In one case detailed in the report a patient was discharged with a major headache. In fact a hospital employee told state surveyors the patient should have been transferred to another hospital.
The patient's mother "felt the patient received a lack of care."
The report cites the records of several patients who needed MRIs, but had to be sent to another hospital for a diagnosis.
The state inspectors also cited the hospital for failing to provide proper transfer orders for the same patients.
A review of hospital records showed the facility couldn't perform the ordered MRIs due to a shortage of MRI technicians.
"The facility failed to provide MRI services" in six of six records, the report states.
Despite the multiple failures the hospital failed to report the "infrastructure" failures as required under the state Medical Care Availability and Reduction of Error Act.
Also cited was a federal law, the Emergency Medical Treatment and Labor Act, barring hospitals from discharging patients prematurely.
In addition to the patient with the serious headache, other improperly transferred patients cited in the report included a stroke victim and a patient who fell from a ladder while putting up an 85 inch high curtain and apparently eloped without treatment at either hospital.
State inspection records show delayed reports were not all negative. Delayed reports on UPMC Altoona and the First Hospital of Wyoming Valley concluded that the facilities were in compliance with state and federal laws and regulations.
A report clearing another hospital complaint states that a report dating back to April was finally concluded on July 17 once state inspectors were able to visit the facility.
Contact: wfrochejr999@gmail.com