Hospital Cited For CPR on DNR Patient

By Walter F. Roche Jr.

An Allegheny County hospital has been cited by the Pennsylvania health officials for initiating resuscitation on a patient who had completed an advanced directive stating his desire not to have that happen.
The incident occurred in mid-July at the 328-bed St. Clair Hospital in Pittsburgh.
According to the recently released inspection report from the state Health Department, the unnamed male patient was brought to the hospital on July 17 from a personal care home. Hospital staff later verified that he was on hospice care at that facility, according to the report.
Several hours later the patient was found unresponsive and cardio pulmonary resuscitation was initiated, inspectors reported following an Aug. 14-15 visit to the hospital.
"The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives," the report states.
The report does not include any information on the results of the resuscitation efforts.
In response to questions about the report a hospital spokesman said that the facility had self reported the incident to the state.
"St. Clair Hospital recently reported to the Pennsylvania Health Department an event in which a patient transferred from a personal care home was resuscitated despite having earlier filed a "do not resuscitate" code status," the spokesman said.
He added that a plan of correction had been filed with the state and approved. It is now being implemented, according to the statement.
The plan calls for a series of training sessions for staffers with subsequent audits to ensure that directives are being followed. The hospital will also notify operators of personal care homes and assisted living facilities that send patients to St. Clair of its policies regarding advance patient directives.
Under the plan a patient's advance care directives will be entered on his or her record upon admission.
"The appropriate code status designation will be entered into the patient's medical record upon admission," the report states.
"This event underscore St. Clair Hospital's objective to ensure accurate communication regarding patient wishes about end-of-life care," the hospital statement continued.
In addition to the failure to follow a patient's directives, St. Clair was cited for failing to administer written orders of a practitioner and failure to ensure that cardiac monitoring equipment was functioning properly. A cardiac monitor had been ordered for the patient but the first reading was recorded only after he was found unresponsive, inspectors reported.
In response St. Clair said it would implement a plan to increase cardiac monitoring and to train staff on how to use the equipment.
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Admissions Frozen at Privatized Metro Facility

By Walter F. Roche Jr.

Citing violations of state and federal laws and regulations state health officials have ordered a freeze on admissions at the Nashville nursing home which Metro Nashville officials privatized and turned over to a private for profit company three years ago.
The order issued late last week by state Health Commissioner John Dreyzehner also imposed fines totaling $7,500 on the facility now known as Nashville Community Care and Rehabilitation at Bordeaux.
Under an agreement with Metro operation of the 419 bed was turned over to Signature Health Care, a chain of nursing homes, which has been cited by the state for deficiencies at its other facilities.
Dreyzehner said a special monitor was also appointed to oversee operations of the facility at 1414 County Hospital Road.
The freeze was imposed based on a complaint survey conducted by state health inspectors from Sept. 24 to Sept. 27.
According to the commissioner, violations uncovered related to the administration of the facility and and patient rights.
The notice, effective Oct. 19, bars the facility from admitting any new patients until further notice. The nursing home is required to post a copy of the order at its main public entrance "where it can be plainly seen."
The nursing home can appeal the findings and the two fines of $5,000 and $2,500 to a state board.
In announcing the freeze Dreyzehner cited a state law that authorizes the commissioner to suspend admissions "when conditions are determined to be, or are likely to be, detrimental to the health, safety and welfare of the residents."
Metro's agreement with Signature privatizing the Bordeaux facility has not been without controversy in part based on the amount of money the city is committed to provide to help underwrite its losses.
The initial lease was signed in 2014 and was renewed for another four years in 2016.
Another Signature facility, Signature Health Care at Saint Francis in Memphis was cited by the state in March for multiple violations of state and federal regulations. As a result the nursing home had its Medicare agreement terminated and the agency ceased any further payments.

Highly Critical Einstein Report Pulled Back

By Walter F. Roche Jr.

A highly critical inspection report on the Albert Einstein Medical Center has been taken of the Pennsylvania Health Department web site and an agency official says it had been posted prematurely.
The report, which was posted in early August, cited the 701 bed facility for failing to adequately investigate four unexpected patient deaths.
The report also charged that Einstein refused to allow state surveyors to interview key staffers and examine records.
Einstein declined comment when first contacted by this blog prior to the posting of a report on the report in early August.
April Hutcheson, spokeswoman for the state Health Department said the report had been posted "inadvertently. It was not complete. It will be posted 41 days after is complete."'
 Although that report was based on a May visit to Einstein by state inspectors, the state has posted a subsequent Einstein report based on a visit in August. In addition the now withdrawn report was based on cases dating back to 2016.
The withdrawn report cited Einstein for failure to comply with state and federal requirements in serious cases "involving the clinical care of a patient that results in death or compromises patient safety."
The report included a plan of correction filed by Einstein in which they promised to institute new patient safety protocols and to use those new standards for all serious events beginning on July 1.
The hospital, however, repeated the assertion that some of the records sought by state inspectors at the time of the inspection are "peer review, protected, privileged documents, entitled to protection under federal and state law."
The first case cited was of a patient who was admitted in July of 2016 was found looking pale and unresponsive on Aug. 7, 2016. Records examined by the surveyors attributed the death to "excessive sedative use leading to hypo-ventilation and brain anoxia."
The second case involved an unidentified patient who underwent a colonoscopy on Sept. 23, 2016 only to return "with worsening abdominal pain." The report states.
The patient, who had apparently suffered a colon rupture, did not survive. The report states the patient had gone home the same day as the procedure against medical advice.
In the third case a patient reported to the emergency room on June 21, 2016 with "agitation and psychiatric symptoms."
When the patient asked for something to eat a sandwich was provided. The patient was choking by the time the nurse returned. The patient subsequently expired.
State inspectors asked for records showing required reviews were performed following the death. "None were provided," the inspection report stated.
Another death occurred following an esophageal intubation in February. When state surveyors asked for documentation and the results of a "root cause analysis," they were told the documents were confidential and "protected."
In addition, the report states, that no completion dates were included for "action items" set to be implemented as a result of the incidents.
Cited in the report was a requirement by licensed health facilities to "track medical errors and adverse patient events, analyze their causes and implement preventive actions and mechanisms."
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Hershey Self Reported Citation Cases

A spokesman for the Milton S. Hershey Medical Center said today that the five citations against the facility in August occurred in a state inspection triggered by the facility self reporting issues relating to the care of three patients, two of whom did not survive.
The five citations were issued in August by the state Health Department of Health.

Hershey Cited in 3 More Cases, 2 Deaths

By Walter F. Roche Jr.

Just weeks after being cited for deficiencies in the care of a child who died while under treatment, the Milton S. Hershey Medical Center has been cited for mishandling three more cases. In two of the three cases, one involving a child, the patients died.
The medical center located in Hershey, PA. was cited in August for the three new cases following a special monitoring survey by inspectors from the Pennsylvania Department of Health The July visit, according to a center spokesman,  was triggered when the facility self reported the three cases.
 A total of five citations were issued in the new report dated Aug. 2..
In two of the new cases, the facility was cited for failure to provide expected emergency services.
"The patient has a right to expect emergency procedures to be implemented without unnecessary delay," the report states.
In the case of an unidentified child under treatment for an infection, the state inspectors concluded that Hershey personnel unduly delayed calling for a rapid response team .
'The team "should have been called much earlier, about noon," the state report continues citing an interview with a hospital employee.
The team was not called until 3:30 p.m. or 3.5 hours later, the inspectors found.
Hershey, in response to questions about the pediatric case said the patient had "lifelong medical deficiencies" and was being treated for a "serious infection."  Hershey was cited for failing to timely upgrade the patient's care by a transfer to the pediatric intensive care unit, the hospital acknowledged
In a recent prior report, Hershey was cited for failing to adequately monitor a boy who had been placed in a heating blanket. The patient's temperature had reached 107 degrees when finally discovered. That patient also died.
In the second new case an adult patient who was later found to have suffered a stroke was not quickly provided a drug that could have minimized symptoms.  The delay was attributed to a difference of opinion among staffers about the correct diagnosis, Hershey officials stated.
When the stroke diagnosis was finally made, it was too late to administer the drug. The report does not detail the patient's ultimate outcome.
In the third new case, there was a delay in getting medication to a patient who had suffered a fall and suffered a sub-dural hematoma.
According to the report there was an hour and 47 minute delay between the time the drug was ordered and when it was finally delivered.
An employee who was questioned by state inspectors about the delay, said an emergency department nurse had said the drug would not be administrated immediately because a shift change was scheduled shortly. That nurse later denied any recollection of making that comment.
In its statement in response to questions about the new citations, Hershey said, "Instances such as this are inconsistent with the high quality care our community has come to expect from us - and which we expect from ourselves. We deeply regret when we fall short of those expectations."


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Nursing Home Fined; Admissions Barred

By Walter F. Roche Jr.

A Nashville nursing home has been fined $15,000 and barred from admitting any new patients after an inspection showed multiple violations of state and federal laws and regulations.
Records show that dozens of patients of the facility needing critical maintenance medication went multiple times without getting doses of drugs for diabetes, hypertension and convulsions.
The fine  and admissions freeze was imposed on the  Nashville Metro Care and Rehabilitation, formerly know as Crestview Health and Rehabilitation, located at 2030 25th Ave. in Nashville.
The action was announced by Tennessee Health Commissioner John Dreyzehner. The nursing home has 111 licensed beds. The suspension followed an on-site inspection from Aug. 21-28.
Dreyzehner said a special monitor has been appointed to oversee the operation of the facility in the interim.
The state inspectors found violations in three general areas; physician services, nursing services and medication administration.
The 65-page inspection report cited multiple sanitation and maintenance problems including  pervasive urine smells.
One nursing home worker told an inspector, "The urine smell is between (room) 204 and 205. It's not as strong as it usually is."
The report shows the home had long term staffing problems and at times only a single registered nurse was on duty for an entire shift. It often relied on staffing agencies, but home administrators could not produce a contract with those agencies.
The staffing shortage, inspectors found, led to multiple missed medications for dozens of patients on life sustaining drugs.
When a nursing home administrator was asked about the persistent staff shortage, the response was, "I feel like you caught me with my pants down."
The report cites the home for failure to respond when an unattended patient fell out of bed. The patient's hip fracture was not detected until several days later. According to the report the facility failed to notify the patient's doctor or his legal representative.
The nursing home employee who discovered the patient on the floor told inspectors she didn't know how to enter the incident into the computer system.
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UPMC Hospital Cited for Improperly Filming Patient

By Walter F. Roche Jr.

In what one participant described as a "circus," physicians and other employees of a Bedford County hospital crowded into an operating room late last year to observe and take pictures and videos of an unidentified patient being treated for a genital injury.
The group, which included several employees not involved in the treatment of the patient, took pictures and videos on their personal cell phones of the patient who had not given consent, all in violation of official hospital policy.
The Dec. 23, 2016 incident was investigated by the Pennsylvania Health Department and resulted in a 41-page report which concluded that the UPMC Bedford Memorial Hospital "failed to protect the personal privacy, dignity and respect of the patient."
The 59-bed hospital in Everett, PA is part of the UPMC system. UPMC officials did not respond to a request for comment.
The hospital filed a plan of correction in which officials promised to initiate policy changes to prevent a recurrence. They also reported that physicians and employees involved were suspended for periods of up to 28 days.
The incident came to light when a hospital employee "came forward to complain about photographs that were circulating around the hospital of a patient under anesthesia while in the operating room."
The inspection report, which was recently made public, does not provide complete details on the patient's genital injury, but does state that the surgery involved the removal of a foreign body.
One hospital employee told state investigators, "I was curious. I couldn't imagine how the patient did it," adding, "There was quite a crowd"in the operating room.
"We never had a circus like this before," an employee told investigators.
The report was the result of an on site investigation from May 23 of this year to June 9.
According to the report, in addition to violating the patient's privacy rights, the incident violated a variety of hospital rules, including a requirement that only approved hospital equipment could be used to take photos of patients.
The state investigators also gathered evidence that the Dec. 23, 2016 incident was not the first time patients had been photographed without consent.
"Generally we don't tell that to a patient," one employee told investigators. "It was a medical curiosity," the employee continued. "We are a small hospital. It is commonplace for everyone to know what cases are coming in."
Another employee told state investigators, "I do take pictures of genito-urinary anomalies for educational purposes."
The employee said he did warn colleagues stating, "Stop this is a HIPPA (Health Insurance Portability and Accountability Act) violation," adding that he told the curious employees they could return to the operating room once the patient was anesthetized.
According to the report, a surgeon said before the surgery finally began, "That's enough. We've got to get going."
Another employee stated that at one point, some onlookers were asked to leave "because they did not have enough eye protection for everyone due to the sparks flying from the tools that were being used."
The 2016 incident came more than two years after the disclosure that a physician took a selfie with comedian Joan Rivers, during the surgery that ended her life.
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