Admissions Halted at TN Nursing Homes

By Walter F. Roche Jr.

Tennessee health officials have ordered a halt to any new admissions and imposed fines following inspections showing evidence of patient abuse, including slapping patients, withholding liquids along with verbal and mental abuse.
Ordered to halt any new admissions were Diversicare of Claiborne and Brookhaven Manor of Kingsport.
A 33-page report on the Claiborne facility cited repeated abuse of some patients by a licensed practical nurse. A certified nursing assistant was cited for slapping a patient.
At the Kingsport facility, state surveyors found that a patient who had violated smoking rules, was ordered out of the facility and taken to a local hotel with just three nights paid for.
The report charges that Brookhaven "placed a resident in an environment that was detrimental to his health. Although the resident had appealed his discharge, he was discharged without his medications for multiple illnesses.
The home was cited for failing to transfer the unnamed resident "to the most appropriate facility or setting to meet his or her need in terms of quality services and location."
A $12,000 fine was imposed against Brookhavem while a $20,000 fine was set for Diversicare.

Temple Cited For Restraint Overuse

By Walter F. Roche Jr.

The Temple University Hospital placed patients in the most restrictive of restraints without proper justification, according to an inspection report from the Pennsylvania Health Department.
In a 40-page report just recently made public, surveyors from the state health agency found that staffers at Temple's Episcopal campus "failed to ensure that alternatives to restraints were utilized and proven to be ineffective prior to the application of restraints."
Instead, when state inspectors visited the 198-bed behavioral health facility late last year, they found several patients had been placed in four point restraints, the most restrictive available, without considering less restrictive alternatives.
In addition the report states staffers at the facility failed to remove those restraints in a timely manner and also failed to monitor patients while they were in those restraints.
Asked to comment on the report, Temple spokesmam Jeremy Walter said that the inspectors visited the Episcopal campus as a result of an anonymous complaint.
Although the complaint proved to be unfounded, the inspectors found other issues, Walter said. Stating that those issues were "quickly remedied," he added that "there were no untoward patient outcomes."
Temple also filed a corrective action plan in which it promised to revise policies for the use of restraints,implement an auditing program to ensure it is being followed and educate staff. State officials accepted that plan.
According to the inspection report, the state surveyors found that on Dec. 2 of last year two patients were placed in four point restraints but "there was no evidence" that less restrictive alternatives were considered.
The same was true, according to the report for three other patients placed in four point restraints later in the same month.
In one of those cases, the report states, there was no indication that there was an effort to discontinue the restraints at the "earliest possible time."
Another patient remained in restraints even though he or she was cooperative and had slept for two hours. In yet another case, surveyors found that there was no evidence of compliance with a requirement that there be constant monitoring of patients while being held in restraints.
The facility also was faulted for referring victims of sexual assault to another facility when they were required "at a minimum" to perform a forensic exam and utilize a rape kit.
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Crozer Burn Unit Cited on Hygiene

By Walter F. Roche Jr.

The burn treatment unit at a Delaware County hospital that bills itself as "a national leader in burn care,"has been cited by state inspectors for failing to follow required infection control practices, including compliance with basic hand hygiene.
In a 39-page report recently made public, the state Health Department also found that for years the hospital has been using the wrong liquid to flush hoses used in the treatment of burn patients.
Since 2006, the report states, hospital staffers have been using chlorhexidine instead of bleach to flush hoses in the hydro therapy room.
Although staffers were required to immediately decontaminate their hands after removing gloves between patient contacts, the state surveyors found that practice was not always followed.
"I witnessed a physician scratch his nose and scalp, put on personal protective equipment and then enter a patient's room," a hospital employee wrote in an email exchange.
The same employee, who was conducting a hygiene compliance audit, wrote that when two residents attempted to follow the doctor into the same patient's room wearing only a gown "I asked them to wash their hands prior to entry and they stated, 'We never had to wash our hands before,'"
Andrew Bastin, a Crozer spokesman, said the facility would be filing a corrective action plan by the April 1 deadline.
"Crozer-Keystone Health System is committed to providing exceptional care with an emphasis on patient safety. Routine inspections from the Pennsylvania Department of Health are a valuable way to identify opportunities for continued improvement," he wrote in an email.
In their report, the state surveyors noted that despite prior internal findings that the expected 100 percent compliance with hand hygiene practices was not being achieved, no action was taken by patient safety and a local governing body.
quality panels established to ensure standards were being met.
"There was no documentation of any actions taken by the local governing body with regard to the staff's failure to meet the benchmark for hand hygiene compliance of 100 per cent," the report states.
In fact the hospital's own audit records showed the hand hygiene compliance rate declined from October of 2016 to October of 2017.
As for the hospital's governing body, the report states that the panel "failed to ensure that the patient's right to care in safe environment was maintained."

Washington County Home Cited, Fined

By Walter F. Roche Jr.


Tennessee health officials have ordered a Washington County nursing home to cease admitting any new patients after state inspectors found multiple violations at the facility.

The order and fines totaling $6,000 against the Family Ministries John M. Reed Center in Limestone were announced today by state Health Commissioner John Dreyzehner. The facility is licensed for 63 beds.

The commissioner said the violations were uncovered in three areas; nursing services, medical records and pharmaceutical services.

In addition he said a state monitor has been appointed to oversee operations at the home.

Philadelphia Hospital Cited on Life Safety

By Walter F. Roche Jr.

A major Philadelphia hospital has been cited for multiple deficiencies following a Medicare inspection of fire protection and other building safety requirements.
The four day January review at Pennsylvania Hospital found deficiencies in several buildings including missing fireproofing on structural beams, fire alarms that were partially inoperative and exposed electrical wires.
The 520-bed hospital, part of the University of Pennsylvania Health System, was inspected from Jan. 9 to Jan. 12 for compliance with provisions of the federal Life Safety Code.
Asked for comment, a Penn Medicine spokeswoman said," We worked to correct the items in the report as quickly as possible as well as put alternative protections in place to ensure the safety of all occupants."
She said the state findings "were part of a routine regulatory inspection," adding they were "very common in an active occupied hospital building. At Penn Medicine, patient safety is our number one priority."
Other findings include the failure to maintain the fire resistance rating of common walls and or on stair tower enclosures.
On the sixth floor of one building a door failed to positively latch. In several locations the state inspectors found unsealed penetrations. At another location they found a fire alarm system component with an inoperable component.
A review of fire sprinkler systems found that some gauges had not been serviced within the five year limit. Smoke compartments in some sleeping locations exceeded the maximum area.
According to the report, structural steel in the neurosurgery building lacked fire protection.
Also cited was the fact that the control panel for a fire alarm system in one building was located in a basement under lease by another party, raising concerns about accessibility in the event of an emergency.
In a parallel Medicare review of patient care, inspectors cited the hospital for failure to dispose of expired medications.
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Two Suicides in Five Days at Belmont

By Walter F. Roche Jr.

Two patients at a Philadelphia behavioral hospital committed suicide in a five day period, according to a court suit and an inspection report by Pennsylvania Health Department.
The deaths on April 24 and April 29 of last year occurred at the Belmont Behavioral Hospital, part of Acadia Healthcare,  a Tennessee based company.
In the April 24 death, which was detailed in a health department inspection report, the patient hung himself in an area that was supposed to be free of fixtures that could be used for ligatures.
The April 29 death involved Jerry W. Gates, 59, a patient who was transferred to Belmont following treatment at a Chester County hospital for dizziness and reporting that "he was hearing voices telling him to harm himself."
The suit charges that despite the diagnosis Belmont determined he "presented a low risk of suicide" and suicide precautions were not provided.
The suit charges Belmont and its parent company Acadia Healthcare with negligence and wrongful death. In a 19-page answer Belmont and Acadia denied any negligence or liability.
The complaint charges that Gates was able to wander from room to room without any supervision and he was not provided with medication for his known insomnia.
 The suit adds that he was found at 4:10 a.m.lying on the floor "bleeding profusely from gaping wounds of the neck caused by a portion of a picture on the wall with which he stabbed his neck.
The suit charges that the facility lacked sufficient and appropriately trained staff.
Acadia, the complaint states, was a direct participant and exercised corporate control over Belmont.
Calling the care provided "a gross deviation from accepted standards of care," the complaint charges the defendants with "flagrant and gross negligence."
In their answer, the defendants acknowledged that Gates was found bleeding from a neck wound. but denied he was found lying on the floor or that he died on the way to a hospital.
"It is specifically denied that Gates was not supervised and was allowed to roam freely without any supervision," the answer states, adding that "all liability against defendants for wrongful death are denied."
As reported previously on this blog, a second suicide at Belmont was detailed in a state inspection report. In that case an unnamed patient hung himself. The state cited Belmont for multiple deficiencies including lack of staff and failure to have facilities designed to prevent suicides.
In fact state inspectors declared a state of imminent danger when they visit in early November of last year.
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Philadelphia Hospital Cited In Suicide

By Walter F. Roche Jr.

A Philadelphia behavioral hospital has  been cited in the suicide death of a patient and a host of other violations of state requirements' many involved in the treatment of patients with Electro Convulsive Therapy (ECT) ,in a recently released report..
 The report on the Belmont Behavioral Hospital was first made public without an approved corrective action. The agency normally posts inspection reports only after the submission of an approved plan of correction.
"An approved plan of correction is not on file," the report stated.
Mark Schor, a Belmont official, said the facility did submit a plan of correction and that state officials had accepted it.
The latest version of the inspection report posted today shows that several parts of the corrective action plan have been accepted while others have not.
Schor also said the hospital is in the process of building a 250-bed state-of-the-art replacement facility, scheduled to open in late 2019.
According to the report, based on a Nov. 9 visit to the hospital, inspectors declared a state of immediate jeopardy after discovering numerous violations of anti-ligature requirements, rules set to minimize the risk of suicides.
The failure to comply with those requirements "resulted in the suicide death of one patient," the report states.
The patient was pronounced dead on April 24 of last year.
"The patient was found hanging from a loopable point on a bathroom anti-ligature door," the report states, adding that in addition the hospital failed to request an autopsy report and forms on the disposition of the body were not completed.
The hospital failed to provide a safe setting, the report continues, adding that a hospital psychiatrist "did not document the observations and special precautions" needed for the patient.
The facility did immediately change its policy to require that all patients with a suicidal risk be observed by staff every seven minutes. As a result the state of immediate jeopardy declared at 12:14 p.m., on Nov. 9 of last year was lifted at 7:46 p.m.
In its corrective action plan Belmont said they had designated a patient safety officer and that policies and  procures for ECT treatment were reviewed and revised.
Belmont is part of the Acadia Health Care LLC, a company that operates some 579 treatment facilities.
Other findings by the state Health Department surveyors included the failure to properly monitor patients who had undergone ECTs. During the visit two patients were observed in the treatment area without any staff present.
Still other violations included medication carts left unlocked and unattended and failure to maintain complete records showing how many vials were used on ECT patients. There was "no documented evidence of how many vials were delivered to the ECT room," the report states.
Inspectors also cited failure to respond to grievances within a seven day limit and failure to secure patient records to ensure confidentiality. They observed 166-pages of patient related data in open view.
Inspectors also said Belmont "failed to ensure a sufficient number of nursing staff were available to meet the nursing needs of the patients."
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