Vets Home Charged with Neglect

By Walter F. Roche Jr.

A paraplegic under treatment in a state run veterans nursing home in Pittsburgh, PA. was left sitting on a bedpan for two days and suffered a pressure ulcer and other injuries as a result, according to a report by state health surveyors.
The report, just recently released, charges the facility with neglect for not only leaving the veteran helpless on a bedpan for two days but also for failing to provide a shower and other sanitary care services.
The unnamed patient at the Southwestern Veterans Center in Pittsburgh suffered actual harm due to a bedpan being left underneath him and peri-care not being completed, the report states.
"The facility failed to make certain that a resident was free from neglect," the report states.
After examining the nursing homes records on a July 12 visit to the 236-bed facility, the surveyors found that the male patient was placed on a special bedpan on June 10 and was found on July 12 in the same situation.
A staffer who examined him at 6:30 a.m. on June 12 described a reddened area approximately 24.5 centimeters in diameter and 1.5 centimeters thick.
The patient had an "unstageable pressure ulcer" and "injury to the sacrum" with the bedpan being a contributing factor.
The patient remained on the bedpan even though he was supposed to be turned and repositioned periodically to prevent bedsores.
Interviews with several staffers involved in the patient's care acknowledged to state surveyors that the bedpan was not removed until June 12.
The report states that additionally the patient was not provided with needed peri-care over the two day period.
The inspectors also cited the center for failing to develop a comprehensive care plan for the same patient.
The facility filed a plan of correction reported the patient's care was being re-assessed and wound care was being provided. They also promised to re-assess the needs of other residents who needed to be repositioned.
The plan also includes staff retraining by Affinity Health Services.The plan calls for the corrective actions to be in place by Sept. 1
Asked to comment on the report, Joan Nissley, spokeswoman for the Department of Military and Veterans Affairs said,"The Bureau ensures that the provision of quality health care for our Veteran residents and their spouses is delivered in a caring and dignified manner while ensuring compliance with all appropriate state and federal regulations."

3rd Hospital Cited in a Telemetry Death

By Walter F. Roche Jr.

Another Pennsylvania hospital has been cited in a telemetry related failure that ended with a patient's death.
In a report recently made public, state health department surveyors found that two staff nurses at the New Lifecare Hospital of Mechanicsburg failed to respond when told the alarm had sounded on a patient on a cardiac monitor.
In fact, the report states, the patient was off the monitor for approximately 45 minutes before a technician found the patient "pale, no pulse and non-responsive."
After reviewing the records of the June 8 incident, state surveyors declared a "state of immediate jeopardy." The emergency declaration requires hospital officials to come up with an immediate corrective action plan. They did so nearly four hours later.
The patient, the report states, was resuscitated and transferred to another hospital but died less than an hour after transfer.
The report comes as the facility is in the final phases of a permanent shutdown. Announced last month the closure is expected to become final early next month putting over 120 employees out of work.
Officials of New Lifecare and its parent company did not respond to requests for comment.
Hospital records show the patient was checked at 1:30 p.m. and "no distress was noted." It was nearly an hour later at 2:28 p.m. when a technician found the patient unresponsive. The patient was revived and transferred to another hospital at 3:03 p.m.
The surveyors reported that the technician monitoring the cardiac monitor "told two nurses that the patient's monitor needed to be checked." Neither nurse went to check the patient.
The report cites the hospital for failure to follow the orders of the patient's doctor, who had ordered a cardiac monitor.
In addition the surveyors found that staffers administered drugs to the patient without a physician's orders. In fact in three other cases of patients who suffered cardiac incidents, medicines were administered without a doctor's orders.
In yet another finding the surveyors found that hospital staffers failed to follow proper procedures in the use of restraints.
The hospital filed a plan of correction which included a new requirement for nurses to respond to monitor alarms within two minutes. They also agreed to have on-call physicians available 24 hours a day-seven days a week and to re-educate staff on proper procedures for medications.
Earlier this year state surveyors cited the Nazareth Hospital in Philadelphia for failure to respond to a telemetry alarm.More recently Paoli Hospital was cited when a telemetry alarm was repeatedly silenced despite the lack of response from staffers assigned to check on the patient.
In both cases, the patient died.
Contact: wfrochejr999@gmail.com

Greeneville Nursing Home Cited in Elopement

By Walter F. Roche Jr.

A Greeneville, Tenn. nursing home has been hit with an admissions freeze and $6,000 in fines after a patient with a history of wandering walked out of the facility and fell down a 15 foot embankment suffering cuts and abrasions.
The patient's elopement occurred despite the fact that an alarm sounded as he walked out the door of the Loughlin Care Center on July 3.
State surveyors reported that a receptionist heard the alarm, peeked out the door but did nothing else.
"I peeked through the window and didn't see anything so I reset the alarm," the receptionist told state inspectors. "No one told me to go outside and look around," she added.
A landscape worker subsequently went into the home and reported that a patient had fallen and was injured.
The state report on the incident concludes that the 90-bed facility placed the patient "in an environment detrimental to health, safety and welfare."
Meaghan K. Smith, a spokeswoman for Ballad Health, which owns the facility, said the incident was self reported to state triggering an automatic investigation
She said the facility had filed a corrective action plan that was accepted by federal officials but she acknowledged that the plan had yet to win state approval.
State Health Commissioner Dr. John Dreyzehner ordered a freeze on any new admissions to the home, imposed the $6,000 in fines and appointed a special monitor to oversee actions at the facility.
Nursing home records show the patient was wearing an alarm device known as a "Wanderguard" which triggered the alarm when he followed a landscape worker out the front door.
The state surveyors also noted that five other patients at the facility with a wandering history had improperly installed Wanderguards. The alarms were attached to their wheelchairs not to their legs.
As for the patient who was injured, surveyors noted that he actually fell three times during the incident.
The unnamed patient was treated for cuts and bruises at a local emergency room, the report states.
The facility failed to ensure that a resident was free from an avoidable accident with injuries, the report concludes.
The Ballad spokeswoman said,"The nursing home has taken steps to update security procedures that we believe will improve the safety of residents and mitigate the opportunity for any similar event to occur in the future."
Contact: wfrochejr999@gmail.com

Too Many Empty Beds Found on Medicare Review

By Walter F. Roche Jr.

A suburban Philadelphia hospital specializing in bariatric surgery has been cited during a Medicare re-certification review for going without a single inpatient on nearly 150 days.
Surveyors from the Pennsylvania Health Department concluded that the Forest Health Medical Center in Langhorne Bucks County failed to meet the requirements of the federally funded Medicare and Medicaid programs.
The hospital did not file a plan of correction acceptable to the state.
Surveyors examining hospital records found that the patient census was zero on 146 days over a 12 month period.
"The facility failed to function as a hospital," the report states.
The Pennsylvania facility is part of the Barix Clinics, which operates a similar facility in Ypsilanti Mich. According to the report the hospital is licensed for 23 medical/surgical beds.
Health is licensed for xxx beds but the records showed they went largely unoccupied.
State inspectors visited the facility on two separate days, March 5 and June 18, and on both of those days the in-patient census was zero.
The hospital, the report states, was "not primarily engaged in providing services to inpatients."
In the review of hospital records the surveyors found that the average daily census ranged from 1.2 to 3.3 patients.
Hospital officials did not respond for requests for comment.
Contact: wfrochejr999@gmail.com

State Cites Paoli Hospital in Telemetry Error, Death

By Walter F. Roche Jr.

For the second time in four months state officials have cited a Pennsylvania hospital in a case in which a patient died when a telemetry alarm was mishandled.
In a report on the Paoli Hospital recently made public, state surveyors found that the hospital, part of Main Line Health, "failed to ensure a safe environment for patients on telemetry."
Main Line spokeswoman Bridget G. Therriault said the incident was "the result of employee conduct that violated our established policies, procedures, and practices. The employee involved in the event has been terminated."
The state health surveyor, who visited the 231 bed hospital on a complaint investigation on June 18. declared a state of "immediate jeopardy" after reviewing records relating to the patient who died on May 28.
The hospital responded with an immediate action plan later in the day and the state of immediate jeopardy was lifted. However the facility has yet to file an overall plan of correction satisfying state regulators.
"An approved plan of correction is not on file," the report states.
The records reviewed showed that when a nurse went to check on the patient, whose condition was being monitored electronically, there was no pulse. A code blue was called but the patient had "passed away," the report states.
The records reviewed by the state showed the technician assigned to monitor the patient had repeatedly silenced the alarm after attempts to reach the nurse assigned to the patient failed. Those failed efforts came on phones provided by the facility.
The inspection showed there were repeated failures with the phone system with battery packs falling out. The report states that some employees had resorted to taping the batteries in an attempt to keep them in place. Other used elastics to hold the batteries in position.
The battery pack falls out all the time, one hospital employee told the surveyor.
According to the report not only did calls go unanswered but callers could not even leave a message. And even when calls went through reception was poor.
"Sometimes we cannot make or receive calls," another employee told the surveyor.
The report states that alarms were not to be silenced until the monitor technician "establishes direct verbal contact with the nurse caring for the patient."
Earlier this year the state health agency cited Nazareth Hospital in a similar incident involving a death and the failure of telemetry monitoring.
Therriault said the hospital instituted its own investigation of the incident and reported it to state officials.
"In addition, we reached out to the patient’s family to explain what had transpired and to express our deepest regrets," she said in response to questions.
She said that hospital officials were continuing to work with state officials in developing action plans to address outstanding issues.
"Main Line Health’s first priority is to ensure the safety of all those who rely on us for care," she concluded.

Admissions Barred at Knoxville Nursing Home

By Walter F. Roche Jr.

New admissions to a Knoxville nursing home have been barred after state inspectors found that a patient there suffered fractures to both knees from an avoidable accident but didn't even get to see a physician for over a week.
Tennessee Health Commissioner John Dreyzehner ordered the admissions freeze and imposed $30,000 in fines on the Westmoreland Health and Rehabilitation Center, a 222 bed facility.
In a 55-page report state surveyors said the woman suffered the fractures on Nov. 11 of last year when a certified nursing assistant attempted to change the patient's sheets without the assistance of a second staffer, as had been ordered.
The patient slid off the bed and landed on her knees crying out in pain, according to the report.
"The fractures were extremely painful," the report states.
After reviewing nursing home records and interviewing staffers, the state inspectors found that despite the patient's repeated complaints of severe pain, X-Rays were not taken until five days after the fall and it was another four days before she was seen by an orthopedic specialist.
The unnamed woman was then hospitalized and treated for the fractures. She died on Dec. 18.
The state surveyors learned that the delay was apparently the result of a note posted at the nurses' station telling staffers they were not to contact the physician or his nurse practitioner "until contact has been made with the on-call nursing manager."
One staffer told the inspectors that the note disappeared after nursing home officials learned they were being sued.
The home's physician told the state surveyors he only learned of the bilateral fractures from their call. He told them he should have been notified about a fracture.
The report states that the physician and the home's director of nursing also never assessed the patient.
Under Dreyzehner's order the home was fined $5,000 each for six violations including failure to notify the physician of a significant change in a patient's condition and "placing a resident in an environment that was detrimental to their health, safety and welfare."
Contact:wfrochejr999@gmail.com

Pa. Hospital Cited for Compounding Errors

By Walter F. Roche Jr.

In a scathing report that eerily echoed details of a five-year-old deadly national outbreak, a Pennsylvania hospital has been cited with multiple violations of drug compounding standards placing cancer patients in immediate jeopardy.
The findings by the Pennsylvania Health Department forced the Pottstown Hospital to immediately shutdown its cancer center pharmacy where supposedly sterile drugs were being compounded for administration to cancer patients.
The report concluded that hospital management and staffers "failed to ensure established procedures for hand hygiene and donning protective gear were followed for the compounding of hazardous drugs."
State surveyors observed staffers working under hoods without required protective gear. Numerous violations of the industry standard code known as Chapter 797 were observed.
Officials of Tower Health, the holding company for the hospital did not respond to requests for comment. The hospital did file a corrective action plan with the state in response to some but not all of the deficiencies.
State surveyors also cited Pottstown, a 232 bed facility, for an array of violations of the federally mandated Life Safety Code. The report states that the main hospital building "exceeds the maximum story height allowed" and multiple areas were found to lack the required fire rating.
Other violations also were noted in several areas other than the cancer center pharmacy.
Staffers failed to follow proper procedures for blood transfusions and mold was observed in an ice machine.
Still other deficiencies included failure to ensure the privacy of patient records, failure to maintain infection control in multiple areas and improper cleaning of endoscopy equipment.
IV bags were observed without expiration dates and expired gloves and drugs were also observed in the endoscopy area.
In the clean room where critical procedures were performed gaps were observed on counter tops, floors were damaged and even when microbial sample showed contamination, no action was taken. According to the report there were over 30 incidents of microbial growth without documented follow up.
The facility "failed to ensure environmental microbial samples were evaluated," the lengthy report states.
The descriptions in the report were similar to the court testimony in the recent trials of former officials of the New England Compounding Center, the company blamed for the 2012 fungal meningitis outbreak.
In those trials federal investigators described similar deviations from the 797 standards including the failure to take corrective action when environmental tests showed evidence of contamination in the clean rooms. The two NECC official were found guilty of racketeering, mail fraud and related charges and are now serving prison sentences.
Still other citations included failure to have adequate post anesthesia services for pediatric
surgical patients and failure to maintain proper temperatures in an operating room.
Pottstown was one of five hospitals purchased by Tower Health from Community Health Associates last year for $418 million.
Another hospital purchased from CHA was the Brandywine Hospital in Coatsville, which was also the subject of a recent critical health department report.
That facility was cited for failure to comply with the state Child Protective Services Act. According to the surveyors, hospital staffers watching a monitor observed a visitor touching a child in an appropriate manner but subsequently failed to properly report the incident immediately. Instead, a report was filed three days late, the report states. The incident occurred on Aug. 27, 2017, two months before the purchase.
Brandywine also was cited for failure to properly follow up on patients who had discharged themselves against medical advice.
The surveyors found that Brandywine failed to contact the patients' outpatient therapists.
Contact: wfrochejr999@gmail.com