Vet Home Errors Caused Actual Harm

By Walter F. Roche Jr.

A Pennsylvania nursing home serving veterans failed to give a patient needed treatment resulting in "actual harm," including hospitalization and surgery to treat necrotic pressure ulcers, according to a state Health Department report.
Cited by state surveyors was the Southeast Veterans Center in Spring City Chester County which was the subject of an Oct. 10 inspection to determine whether the facility met the minimum requirements for participation in the federally funded Medicare and Medicaid programs. The report concluded that the veterans center did not meet those standards.
The facility failed to monitor and assess the patient's pressure sores and failed to provide necessary treatment for those sores, the report states, adding that those failures resulted in actual harm to the unnamed patient.
Administrators of the 238-bed state run nursing home did file a plan of correction in response to the report and promised to examine each current resident for evidence of pressure sores and to institute a re-education program for employees and to set up an audit program to ensure that all patients get the proper pressure sore care.
Officials of the state Department of Military and Veterans Affairs, which runs state veterans homes, did not respond to requests for comment.
The patient, according to the report, suffered from diabetes and multiple sclerosis and required the assistance of two aides to get out of bed. He also had suffered a stroke.
A review of patient records showed the patient needed to be turned and re-positioned and examined at regular intervals, but records verifying those actually occurred were missing. The records indicated he was only re-positioned twice between July 11 and July 15.
"There was no evidence wound treatment was ordered," the report also states.
As his condition worsened the patient was transferred to a hospital for treatment of a wound infection.
He then underwent surgery for a "necrotic infected stage four sacral decubitus.
"The facility failed to provide the services ordered in the plan of care and failed to identify, assess, monitor and provide treatment necessary in preventing skin breakdown," the surveyors concluded.
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Eloping Patient Struck By Vehicle

By Walter F. Roche Jr.

A suicidal patient at a Chester County hospital, who was supposed to be on a one-to-one watch, was able to walk out the door without detection only to be hit by a motor vehicle shortly afterwards.
According to a report by Pennsylvania Health Department surveyors the incident occurred on Aug. 27 at the Chester County Hospital. The surveyors cited the hospital for its failure to protect the patient, a minor, and for its handling of several other psychiatric patients in its emergency department.
The report does not give any details of the injuries suffered by the unnamed patient.
Employees of the 248 bed hospital told the state inspection team that the hospital simply did not have the resources "to handle these patients with behavioral issues. We are dependent on the county to place these patients."
The hospital had yet to file an approved plan of correction when the report was first made public last week. Hospital officials did not respond to a request for comment.
On their Oct. 3 visit to the Penn Health facility observed several patients being kept in hallways due to a lack of available beds.
In fact the eloping patient had just been moved from a patient room to make room for another more critical patient. And the day before that the same patient had eloped by the same door.
The staffer who moved the patient to the emergency area told surveyors,"If I had it to do over again I would not have moved her to a hallway bed."
According to a review of hospital records the patient had told staffers that she needed to go to the bathroom, but instead at 11:50 p.m. exited through an ambulance door, the same one she had used the day before.
The patient, who had been in the hospital for a total of 47 hours, had earlier expressed suicidal ideations telling hospital aides that she didn't want to live anymore. At one point she was placed in a four point restraint, the report states. Then she tried to bite off the restraints.
The surveyors observed other patients in the emergency department bedded indefinitely in hallways. Hospital workers were taking patient histories oin open areas.
They also cited the hospital for failing to protect patients' privacy. One patient was observed in open view removing her gown while undergoing an examination.
Another patient was observed in a loud verbal exchange with security guards.
A hospital employee told the surveyors, "We have to acquire privacy screens."
The staffer assigned to constantly monitor another patient was actually sitting across the hallway from the patient's room.
Citing "a systemic nature of non-compliance," the report states, "A hospital must protect and promote each patient's rights."
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PA Hospital Lacks Staff, Patients

By Walter F. Roche Jr.


A tiny 10 bed western Pennsylvania hospital has been cited for not functioning as a hospital because of its limited staff and hours.
According to a report from the state Health Department the Edgewood Surgical Hospital in Transfer, PA is only open five days a week and locks its doors on those days at 6 p.m. Transfer is located in Mercer County some 70 miles south of Erie.
Inspectors visited the facility in August and September and found there were no inpatients on either day. The survey was conducted to determine if the facility met minimum standards for participation in the federally funded Medicare and Medicaid programs/
"It was determined the facility failed to function as a hospital, as defined by the Social Security Act in that they in that they were not primarily engaged in providing services to inpatients," the report states.
in December 2018, the facility had one inpatient that stayed for a total of 76 hours and 37 minutes.
A review of hospital record showed that the average length of stay for patients was a little over three days. A further review showed where there were no nurses on duty for extended periods.
The surveyors cited a notice displayed at the facility stating that "A doctor is not present 24 hours a day seven days a week."
A review of monthly logs showed that in December of last year the facility had but one inpatient that stayed for a total of 76 hours and 37 minutes.
When questioned about the inpatient census numbers, a staffer acknowledged that in 43 weeks of a 52 week period there were no inpatients and hospital records listed the hospital as "closed" for those 43 weeks.
In a Plan of Correction filed in response to the inspection report, Edgewood officials promised increased staffing and to remain open 24 hours per day seven days a week.
The Edgewood report marks the second time in recent months that a Pennsylvania hospital has been cited for not functioning as a hospital. A Bucks County hospital, Barix Clinic. surrendered its license as a result of the report.
Inspectors found that that the Langhorne clinic had gone 150 days without having a single patient.
The hospital did not respond to requests for comment.


A tiny Pennsylvania hospital specializing in bariatric surgery has closed its doors and surrendered its license to state health officials.
Once part of a nationwide chain, the Bucks County 23 bed facility was part of Barix Clinics. The only remaining facility is located in Ypsilanti, Michigan.
Known as the Forest Health Medical Center, the Pennsylvania facility has been the subject of critical inspection reports by state Health Department surveyors. In one recent report surveyors noted the facility had gone 150 days without a single patient.
The latest report on the Langhorne clinic is the notation that the facility "relinquished" its certificate of licensure.
A closure inspection was completed on June 19.
Several deficiencies had been cited when the facility underwent a Medicare re-certification in 2018. The Barix company signed a settlement agreement with the federal government in 2013 after investigators found that two HIV positive patients had their surgeries canceled when the test results came in.
The Bucks County hospital has posted a notice on its web site blaming the closure on the refusal of insurance companies to provide adequate patient coverage
"Over the past 15 years, insurance reimbursement to small specialty hospitals has declined significantly. After several years of losses we chose to close rather than drastically cut costs and compromise our unwavering commitment to providing the best patient care. We are sorry for any inconvenience this may cause," the notice states.
Following the critical inspection report the hospital did not file a plan of correction acceptable to the state.
"The facility failed to function as a hospital," the report states, noting that the average daily census ranged from 1.2 to 3.3 patients.
The building at 289 Middletown Boulevard in Langhorne has been sold to Capital Health Primary Care.
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Wilkes Barre Hospital Cited Again

By Walter F. Roche Jr.

A Wilkes Barre hospital which was cited for multiple deficiencies last summer has been hit again by a highly critical report by surveyors from the Pennsylvania Health Department.
In a report just made public the state surveyors concluded the PAM (Post Acute Medical) Specialty Hospital, did not meet the basic requirements for participation in the federal Medicare program. The latest report cites the hospital for the way it handled a patient's request to have a so-called full code implemented in a medical emergency'
According to the report the patient had requested to be full code at the time of admission, but was not coded on the date of death, Sept. 9 of this year. The patient died at 2:40 a.m., but a Do Not Resuscitate order was not signed by a physician until 7 p.m.of the same day.
The inspectors also cited the facility for improper handling of several other Do Not Resuscitate orders. In some cases the hospital records showed a lack of verification that a physician discussed end-of-life choices with the patients.
The same facility was cited earlier this year by state surveyors for deficient care provided to patients by nursing staff and a lack of adequate nursing staff. The 36-bed unit is located within the Wilkes Barre General Hospital.
"The nursing service must have adequate numbers of licensed registered nurses and other personnel," the earlier report states.
The latest report also faults the hospital for failing to have dietary orders approved by appropriate staff and for improper handling of organ donor forms.
The hospital did file a Plan of Correction in which it promised to have physicians fully fill out the appropriate forms for end-of-life preferences and for an auditing process to ensure compliance. The plan also calls for disciplinary action to be initiated for non-compliance.
Hospital officials did not respond to requests for comment.
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Tuesday, July 30, 2019
Wilkes Barre Hospital Understaffed?

By Walter F. Roche Jr.

A specialty hospital in Wilkes Barre "showed a systemic nature of non-compliance with nursing services," according to a report from the Pennsylvania Health Department.
The highly critical report, the result of three recent visits to the PAM (Post Acute Medical) Specialty Hospital, cited multiple deficiencies in the care provided to patients by the nursing staff.
Six patients were not re-positioned every two hours as ordered, five patients missed weight checks and no assistance was provided a patient who needed help in feeding.
The facility "failed to ensure that nursing administration provided oversight of nursing services," the report states.
The 36-bed unit is located within the Wilkes Barre General Hospital.
Still other deficiencies included failure to check glucose levels before insulin injection, failure to bathe four patients, delays in performing dietary assessments, and failure to send a patient's record to the emergency room along with the patient. The patient ended up in intensive care suffering from acute respiratory failure.
Other records, the surveyors reported, were filled out in advance and inaccurately.
"The nursing service must have adequate numbers of licensed registered nurses and other personnel," the report states
Also noted in the report was the fact that the state surveyor slipped on a wet floor which had no signage.
A plan of correction filed by the hospital includes retraining of staffers and audits to ensure compliance with standards.
The report noted that the hospital failed to implement a prior plan of correction filed earlier this year in response to another critical inspection report.
Contact: wfrochejr999@gmail.com
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Hospital RN Shortage Triggers Walkaways

By Walter F. Roche Jr.

Nearly a dozen patients at a rural Pennsylvania hospital apparently gave up and walked away after waiting an extended time to be seen in the emergency room.
A state inspection report on the Conemaugh Miners Medical Center cited the facility for failing to ensure the availability of nursing personnel for initial assessments.
Of the 11 patients who walked away was a psychiatric patient who ran away multiple times and was finally found hiding in nearby woods.
State surveyors also cited the hospital for failing to identify a patient who was at risk for self harm and for failing to initiate a one on one observation for a patient at risk for suicide.
Reviewing hospital records, the surveyors found that some patients were kept waiting for over an hour before they gave up and walked out.
Eleven patients of 30 patient files reviewed showed no initial assessments, according to the report on the 30 bed hospital in Cambria county. The hospital is part of the Conemaugh Health System.
An examination of the hospital's staffing records showed that at multiple times only one registered nurse was on duty in critical care areas including the emergency room.
Interviews with hospital employees showed a continuing and worsening problem with staffing.
"All weekend there was one registered nurse in the emergency room," one employee told state inspectors.
Records showed only one nurse was on duty for five of 42 shifts reviewed.
"We lost seven registered nurses since February. None were replaced," the surveyors were told. "Staff are getting bitter about working by themselves.
Another employee described filling out a form reporting "unsafe staffing."
"There is nothing I can do to make this better at this time," another employee said expressing frustration
The hospital filed a plan of correction in which it described renewed efforts to recruit additional registered nurses and licensed practical nurses.
Hospital officials said it was their goal to have an initial assessment performed on emergency room patients within 10 minutes of arrival.
Conemaugh is one of several Pennsylvania hospitals cited in recent months for staff shortages, particularly in emergency rooms. In fact a sister facility, the Conemaugh Memorial Medical Center, was cited last summer for severe and chronic staff shortages.
"It's only a matter of time until someone really gets hurt or we lose a baby," an employee told state surveyors.
In the most recent case a patient at York Hospital died in the emergency room when staffers assumed the patient had left when he didn't respond when his name was called. Staff shortages were cited as a contributing cause.
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Geisinger Facility Cited Again

By Walter F. Roche Jr.

When state inspectors visited a Scranton hospital in August they observed staffers assigned to constantly monitor patients in a mental health unit chatting among themselves and talking on their cell phones.
In addition a search of records showed another patient in the unit who was supposed to be under one-to-one monitoring was not immediately assigned a watcher. The patient had spoken about jumping off a bridge and was considered a suicide risk.
"The facility failed to ensure a staff member was performing a patient required one-to-one direct visual examination," the report states.
The recent visit to the Geisinger Community Medical Center was not the first in which state surveyors found violations of minimum state and federal standards. The same 279 bed facility was cited recently for failure to properly investigate an incident in which a patient was burned during surgery.
A Geisinger facility in Wilkes Barre also has been the subject of multiple critical reports.
In the 13-page Aug. 27 report on the Scranton facility, the surveyors also found ceiling vents that could be used in a suicide attempt and a plastic bag that also could accommodate a suicide effort.
The facility failed to ensure care in a safe environment," the report states.
In a plan of correction filed in response to the critical report, Geisinger officials agreed to quickly replace the ceiling vents and remedy other possible suicide risks.
The hospital also initiated a re-education program for workers in the behavioral unit and barred the use of personal cell phones while on duty.
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Patient Dies Awaiting Care in Hospital ER

By Walter F. Roche Jr.

Staffers at a York,PA hospital concluded that an emergency room patient left without treatment when in fact the patient lay dying in their midst.
An investigation by state surveyors on the Aug. 16 incident at the York Hospital showed staffers passed the dying patient at least a dozen times without checking for vitals. Some passed within 1 to 2 feet of the wheelchair where the patient was seated.
The patient was brought by ambulance to the Wellspan facility at 9:59 a.m. and was discovered unresponsive hours later. The death pronouncement came at 1:31 p.m.
The hospital also was cited for failing to report the incident within 24 hours as required by state law.
Despite a hospital policy requiring periodic rounding, the state investigators review of the patient's record "failed to reveal evidence that anyone had completed rounding, while the patient was in the waiting room."
The nurse who was charged with assessing the patients waiting in the ER never even spoke to or even approached the patient, according to the report.
A review of surveillance footage showed the patient showed no movement from 11:09 a.m. to 12:20 p.m.
The patient, identified as MR1, failed to respond to three calls of his or her name.
The surveyors from the state Health Department noted that two other patients, considered in a less critical status, were treated and released in the interim.
"None of the critical protocols were initiated on the patient," the report states.
The patient had been placed in front of a triage room that was not in use at the time, according to the report.
In a response to the report, the hospital said,"The event has been taken extremely seriously at all levels of the organization."
Wellspan officials called the incident a "rare event," but acknowledged the facility failed to properly care for the patient.
A plan of correction filed by the hospital calls for a series of retraining programs and additional staffing in the emergency room.
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