Tuesday, May 17, 2022

State "Edits" Hospital Incident Reports

By Walter F. Roche Jr.

In increasing numbers the Pennsylvania Health Department has been publicly posting inspection reports on hospitals that leave the public only to guess what prompted the report in the first place.
When asked about the practice, a department spokeswoman said the agency routinely edits hospital incident reports to bring them into compliance with federal requirements.
"The Department of Health continuously evaluates best practices for sharing survey findings on the website to be consistent with the Centers for Medicaid and Medicare Services. The language you mention was a part of that effort," Maggi Barton, the agency spokeswoman responded when asked whether information had been deleted from a report on the Geisinger Wyoming Medical Center.
The report dated Feb. 17 states as follows: "It was determined that the allegation was substantiated. The hospital identified the violation on its own and took effective corrective action prior to the investigation," the report states.

Identical language was contained in a March 24 report on the Geisinger Community Medical Center.
"The hospital identified the violation and took effective corrective action on its own," the report states.
A March 15 report on the Fulton County Medical Center states simply that the facility was found to be out of compliance with federal standards for the Medicare and Medicaid programs.
A March 16 report on the Moses Taylor Hosptal in Scranton states,"It was determined that the allegation was substantiated. The hospital identified the violation on its own and took effective corrective action prior to the investigation," the report states.
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Saturday, May 14, 2022

Patient at City Facility Sexually Abused

Note: This story was updated on May 18 with comment from the city Health Department. By Walter F. Roche Jr.

A cognitively impaired longtime resident of a Philadelphia owned nursing home was sexually abused by a facility employee who was caught naked with the victim in a closed section of the 402-bed facility.
The discovery of the abuse was detailed in a 14-page report recently made public by the state Health Department. When confronted with the incident the employee denied engaging in inappropriate behavior but stated to one supervisor,"I don't know what to say, you need to keep this between us."
According to the report, the relationship came to light on March 11 when an employee was making the rounds and checked Room 560 after hearing some noise in the unoccupied room. When he opened the door he observed an employee, a general mechanic, "completely naked with his clothes in a pile by the window."
The security employee did not see anyone else in the room, but a later review of surveillance camera footages showed the mechanic and the cognitavely impaired patient exiting the same room about two minutes later.
The mechanic eventually told investigators the relationship had become sexual only recently and amounted to "kisses and maybe some fondling." He denied having sex with the patient.
The patient told supervisors they had sex "a few times, total."
She began crying at one point in the interview and stated that she did not want the mechanic to be mad at her and think that she had reported the relationship.
The administrator of the facility, state surveyors reported, kept insisting that the relationship was "consensual despite the fact thay the patient had been diagnosed with cognitive impairment."
According to the report the mechanic was terminated on March 14, just three days after he was observed naked.
The director of nursing said she did not make the staff aware of what was going on because the matter was under investigation internally and by the police.
As for the patient's cognitive impairment, the report cites recent testing and previous diagnoses finding that she did not have a sound mind.
In a plan of correction filed with the state, nursing home administrators said they issued a formal poliicy statement barring sexual relations between staff and patients.
The plan also calls for staff re-education on sexual abuse and the responsibility to report any suspected abuse.
"All residents will be interviewed regarding sexual interactions," the report states, adding that they will be specifically asked about any sexual interactions between residents and staff.
Health Department officials noted that a subsequent inspection by state surveyors showed that all of the cited deficiencies had been corrected.
Contact: wfrochejr999@gmail.com

Tuesday, May 3, 2022

VA RN Failed to Assess Suicidal Veteran

By Walter F. Roche Jr.

An unnamed nurse practitioner at a Veterans Administration facility in Pittsburgh failed to perform a risk assessment on a veteran with a history of suicide attempts and who, subsequently, did kill himself.
That finding was just one of a series of failures by the healthcare worker cited in a 38-page report from the VA Inspector General.
The 78-year old veteran was just one of eight patients with suicidal ideations, who were not given suicide risk assessments by the nurse, the report states.
"For unclear reasons the (nurse) BHNP failed to document suicide risk assessments," the report states, adding that if the assessments had been performed it might have resulted in different interventions.
Other deficiencies by the nurse included failing to get proper informed consent from patients being treated with anti-psychotic medications and failure to inform patients of possible side effects.
Very little information on the the patient who committed suicide was provided except the fact that he had a prior history of suicide attempts and that he had been charged with killing "a significant other."
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