By Walter F. Roche Jr.
Citing a discrepancy between hospital records and video surveilance tapes, state Health Department investigators have concluded that Temple University Hospital workers failed to properly monitor a suicidal patient allowing him to hang himself.
A report on the Sept. 7 suicide at the hospital's Episcopal Campus concludes that while hospital employees were supposed to check on the patient face-to-face every 15 minutes, video tapes showed no one went into the patient's room a single time during a critical more than one hour period.
Nonetheless hospital records stated that the 15 minute checks were dutifully performed.
"Documentation in the medical record showed that 15 minute checks were completed and documented by the mental health technician," the report states.
"The video tape review showed there was a long period of one hour and eight minutes when Patient One was not visualized by a staff member which was in contradiction to the required 15 minute visual checks to be conducted by the staff per hospital policy," according to the report.
"The facility failed to ensure patient monitoring was performed as required," the report states, adding that a registered nurse was ultimately responsible but failed to ensure that the 15 minute checks were actually being performed.
The investigation showed that the unnamed patient tore up a sheet and attached it to a shower curtain rod and then hung himself.
The hospital also was cited for failing to remove ligature risks (the curtain rods) from an area where suicidal patients were being treated. The report does state that the curtain rods in the unit were immediately removed while surveyors were conducting their review.
Further review of video tapes showed there were 17 missed 15 minute checks in the behavioral unit in a two day period including the day of the suicide.
"This placed 21 patients at risk for harm, serious injury or death," the surveyors concluded.
The hospital failed to file an acceptable plan of correction and did not repond to requests for comment.
Contact: wfrochejr999@gmail.com
Friday, October 30, 2020
Wednesday, October 28, 2020
Multiple Covid-19 Violations at PA Hospital
By Walter F. Roche Jr.
State surveyors say multiple violations of Covid-19 care requirements were observed at a 149-bed behavioral hospital, including an employee, who had tested positive for the virus interacting with a patient without properly wearing a face mask.
The details of the September survey at the First Hospital of the Wyoming Valley were included in a report made public late last week. The violations of state and federal rules on care for Covid-19 cases were observed both in person and by viewing surveillance videos at the Kingston facility.
The surveyors visited the hospital on Sept. 4 and again from Sept. 8 to Sept. 10.
The violations ranged from failing to properly screen patients prior to admission to failure to provide oversight of nursing staff to ensure they were properly using Personal Protective Equipment.
Surveyors personally observed an employee using a cell phone, a prohibited practice, in a patient care area.
The facility policy required leaving personal cell phones in a first floor locker room, according to the Sept. 10 report.
The hospital is part of Commonwealth Health, which boasts of its system-wide measures to keep patients and visitors safe during the ongoing pandemic.
A hospital spokeswoman, Annmarie Poslock, said the facility "implemented a plan of correction accepted by the Pennsylvania Department of Health following the September inspection." She said directors and providers have been retrained on infection control protocols established by the Centers for Disease Control and Prevention including the appropriate use of personal protective equipment.
She said the hospital does not currently have any Covid-19 cases. The hospital also was cited for failing to properly screen patients prior to admission.
The report cites three patients who were not pre-screened and later tested positive for Covid-19.
In seven of seven patient records reviewed the hospital had failed to ensure patients were tested prior to admission.
Other screening steps were absent in 12 of 26 records reviewed. Those missing steps included asking patients about any recent elevated temperatures or for other symptoms prevalent in Covid-19 cases.
In its plan of correction the hospital said it would no longer admit patients with positive Covid-19 test results.
In reviewing videos the surveyors observed multiple cases of employees interacting with patients while not wearing masks or not wearing them of other Personal Protective Equipment properly.
As part of its plan of correction the hospital agreed to maintain a list of non-compliant employees.
Contact: wfrochejr999@gmail.com
State surveyors say multiple violations of Covid-19 care requirements were observed at a 149-bed behavioral hospital, including an employee, who had tested positive for the virus interacting with a patient without properly wearing a face mask.
The details of the September survey at the First Hospital of the Wyoming Valley were included in a report made public late last week. The violations of state and federal rules on care for Covid-19 cases were observed both in person and by viewing surveillance videos at the Kingston facility.
The surveyors visited the hospital on Sept. 4 and again from Sept. 8 to Sept. 10.
The violations ranged from failing to properly screen patients prior to admission to failure to provide oversight of nursing staff to ensure they were properly using Personal Protective Equipment.
Surveyors personally observed an employee using a cell phone, a prohibited practice, in a patient care area.
The facility policy required leaving personal cell phones in a first floor locker room, according to the Sept. 10 report.
The hospital is part of Commonwealth Health, which boasts of its system-wide measures to keep patients and visitors safe during the ongoing pandemic.
A hospital spokeswoman, Annmarie Poslock, said the facility "implemented a plan of correction accepted by the Pennsylvania Department of Health following the September inspection." She said directors and providers have been retrained on infection control protocols established by the Centers for Disease Control and Prevention including the appropriate use of personal protective equipment.
She said the hospital does not currently have any Covid-19 cases. The hospital also was cited for failing to properly screen patients prior to admission.
The report cites three patients who were not pre-screened and later tested positive for Covid-19.
In seven of seven patient records reviewed the hospital had failed to ensure patients were tested prior to admission.
Other screening steps were absent in 12 of 26 records reviewed. Those missing steps included asking patients about any recent elevated temperatures or for other symptoms prevalent in Covid-19 cases.
In its plan of correction the hospital said it would no longer admit patients with positive Covid-19 test results.
In reviewing videos the surveyors observed multiple cases of employees interacting with patients while not wearing masks or not wearing them of other Personal Protective Equipment properly.
As part of its plan of correction the hospital agreed to maintain a list of non-compliant employees.
Contact: wfrochejr999@gmail.com
Monday, October 12, 2020
Stabbing Victim Waits 7 Hours for Doctor
By Walter F. Roche Jr.
A stabbling victim, whose case had been classified as urgent, had to wait nearly seven hours after arriving at a hospital emergency room before being examined by a doctor.
That was the finding of surveyors from the Pennsylvania Health Department performing a state licensure inspection of a Montrose hospital.
According to the report on the Endless Mountain Health System hospital the stabbing victim arrived at the hospital at 3:23 a.m. on March 1 with a stab would in the chest. Hospital staff had categorized the case as Level 3 Urgent.
Yet it wasn't until 10:09 a.m. when a doctor examined the patient and ordered a transfer to another hospital for surgery.
The physician "failed to evaluate the patient in a timely manner," the report states.
Hospital officials did not respond to a series of questions about the incident.
The Aug. 20 report also cited the hospital for failure to have a director of anesthesia and for a series of sanitation issues including dirt and dead bugs at the entrance to the emergency room.
The facility "failed to maintain a clean environment," the report states.
The hospital filed a plan of correction which included re-educating staff on triage policy and a monitoring program to ensure compliance.
A stabbling victim, whose case had been classified as urgent, had to wait nearly seven hours after arriving at a hospital emergency room before being examined by a doctor.
That was the finding of surveyors from the Pennsylvania Health Department performing a state licensure inspection of a Montrose hospital.
According to the report on the Endless Mountain Health System hospital the stabbing victim arrived at the hospital at 3:23 a.m. on March 1 with a stab would in the chest. Hospital staff had categorized the case as Level 3 Urgent.
Yet it wasn't until 10:09 a.m. when a doctor examined the patient and ordered a transfer to another hospital for surgery.
The physician "failed to evaluate the patient in a timely manner," the report states.
Hospital officials did not respond to a series of questions about the incident.
The Aug. 20 report also cited the hospital for failure to have a director of anesthesia and for a series of sanitation issues including dirt and dead bugs at the entrance to the emergency room.
The facility "failed to maintain a clean environment," the report states.
The hospital filed a plan of correction which included re-educating staff on triage policy and a monitoring program to ensure compliance.
Wednesday, September 30, 2020
Wrong IV Administered at Wilkes Barre Hospital
By Walter F. Roche Jr.
A patient at a Wilkes Barre hospital was given an IV prescribed for another patient and even after the error was uncovered the patient's doctor was not informed.
That was the finding of an August state licensure inspection at the PAM (Post Acute Medical) Specialty Hospital, a 36-bed facility located within the Wilkes Barre General Hospital.
The IV mixup was only one of several medication errors turned up in the five-day inspection of the hospital in early August. And the same facility was cited twice in 2019 for other violations including a lack of adequate staff.
In the recent report one patient had been prescribed a five percent dextrose in a saline solution at a rate of 100 milligrams per hour.
A second patient had been prescribed a 5 percent dextrose solution in water administered at 50 milligrams per hour.
On Nov. 4 of last year at a shift change at 10 p.m. a nurse discovered that the first patient was getting an IV with the second patients's information on it.
Hospital records showed the patient getting the wrong IV had been administered 80 milligrams of wrong IV before it was discovered.
The report states that despite a hospital requirement that serious medication errors had to be reported to the physician of the patient affected, the records showed no documentation that the notification took place.
In addition the error was not recorded in the patient's record.
In another case, the report states that a doctor's order to increase the dosage of a drug was not implemented. And again the patient's doctor was not informed, according to the report.
In the same inspection state surveyors found that a crash cart had three expired vials of sodium chloride.
The hospital filed a plan of correction calling for re-education of staff on the requirements for reporting medication errors "that have harmed or have the potential to harm the patient."
The hospital also implemented a plan to ensure that expired medications were removed from crash carts.
Hospital officials did not respond to questions about the report.
Contact: wfrochejr999@gmail.com
A patient at a Wilkes Barre hospital was given an IV prescribed for another patient and even after the error was uncovered the patient's doctor was not informed.
That was the finding of an August state licensure inspection at the PAM (Post Acute Medical) Specialty Hospital, a 36-bed facility located within the Wilkes Barre General Hospital.
The IV mixup was only one of several medication errors turned up in the five-day inspection of the hospital in early August. And the same facility was cited twice in 2019 for other violations including a lack of adequate staff.
In the recent report one patient had been prescribed a five percent dextrose in a saline solution at a rate of 100 milligrams per hour.
A second patient had been prescribed a 5 percent dextrose solution in water administered at 50 milligrams per hour.
On Nov. 4 of last year at a shift change at 10 p.m. a nurse discovered that the first patient was getting an IV with the second patients's information on it.
Hospital records showed the patient getting the wrong IV had been administered 80 milligrams of wrong IV before it was discovered.
The report states that despite a hospital requirement that serious medication errors had to be reported to the physician of the patient affected, the records showed no documentation that the notification took place.
In addition the error was not recorded in the patient's record.
In another case, the report states that a doctor's order to increase the dosage of a drug was not implemented. And again the patient's doctor was not informed, according to the report.
In the same inspection state surveyors found that a crash cart had three expired vials of sodium chloride.
The hospital filed a plan of correction calling for re-education of staff on the requirements for reporting medication errors "that have harmed or have the potential to harm the patient."
The hospital also implemented a plan to ensure that expired medications were removed from crash carts.
Hospital officials did not respond to questions about the report.
Contact: wfrochejr999@gmail.com
Tuesday, September 29, 2020
Friday, September 25, 2020
Hospital Failed to Screen for Covid-19
By Walter F. Roche Jr.
A suburban Philadelphia hospital failed to follow state and federal requirements in screening some 91 visitors to the 371-bed facility for coronavirus, according to a report by state Health Department officials.
The report dated Aug. 11 but only made public this week, states that Saint Mary Medical Center "failed to ensure all visitors were actively checked for temperatures and docmented in a log."
A review of hospital records for the first 10 days of August showed that for 91 of 172 visitors there was no documented evidence that these visitors had their temperatures taken."
The facility was not in compliance with state and federal Covid-19 guidelines, the report states.
In a plan of correction filed by the hospital, Saint Mary officials said they implemented an education program for employees on proper screening and maintaining the required log.
The hospital was cited in a separate report for failing to get proper informed consent from another patient. State surveyors were told hospital employees were unable to get a patient signature due to the Covid-19 pandemic.
"The facility failed to follow their policy for obtaining consents during the Covid-19 pandemic," the report states.
In yet another finding state surveyors cited the hospital for giving improper discharge instructions to a patient.
The patient was instructed not to remove nasal packing until the next day when a visit with an eye, ear and throat specialist was scheduled. The patient, however, had no nasal packing.
Hospital officials did not respond to a request for comment.
Contact: wfrochejr999@gmail.com
A suburban Philadelphia hospital failed to follow state and federal requirements in screening some 91 visitors to the 371-bed facility for coronavirus, according to a report by state Health Department officials.
The report dated Aug. 11 but only made public this week, states that Saint Mary Medical Center "failed to ensure all visitors were actively checked for temperatures and docmented in a log."
A review of hospital records for the first 10 days of August showed that for 91 of 172 visitors there was no documented evidence that these visitors had their temperatures taken."
The facility was not in compliance with state and federal Covid-19 guidelines, the report states.
In a plan of correction filed by the hospital, Saint Mary officials said they implemented an education program for employees on proper screening and maintaining the required log.
The hospital was cited in a separate report for failing to get proper informed consent from another patient. State surveyors were told hospital employees were unable to get a patient signature due to the Covid-19 pandemic.
"The facility failed to follow their policy for obtaining consents during the Covid-19 pandemic," the report states.
In yet another finding state surveyors cited the hospital for giving improper discharge instructions to a patient.
The patient was instructed not to remove nasal packing until the next day when a visit with an eye, ear and throat specialist was scheduled. The patient, however, had no nasal packing.
Hospital officials did not respond to a request for comment.
Contact: wfrochejr999@gmail.com
Monday, September 21, 2020
Hospital Cited for Turning Away ER Patient
By Walter F. Roche Jr.
A Clearfield County hospital has been cited for turning away a clearly distressed patient seeking care in the emergency room.
According to a report from the state Health Department the patient was told by a Penn Highlands Clearfield employee to go home and call for an ambulance. Ultimately an ambulance picked up the patient on the hospital grounds and then brought the patient to the emergency room.
In the report state Health Department surveyors cited a federal law, the Emergency Medical Treatment and Labor Act, which requires that a hospital with an emergency room must provide a prompt examination and treatment.
The hospital "failed to ensure that a medical screening examination was provided for one patient who presented to the emergency room," the report states.
The incident occurred on May 18 at 12:42 p.m. when the patient, accompanied by a relative, arrived at the hospital in the front passenger seat. The state surveyors reviewed hospital records and also viewed videotapes showing the patient's arrival.
"The patient was noted to be extremely upset, embarassed and crying," the report states, adding that the patient, who had suffered a fall, came to the hospital under a doctor's instructions.
"The patient was told by an employee they could not help because the patient was a fall risk," the report states.
Officials of the 50-bed hospital did not respond to requests for comment.
In addition to failing to make a required assessment of the patient, hospital employees failed to enter the patient's first visit into the emergency department log.
"The patient should have been entered into the log and then formally transferred," the report states.
The hospital filed a plan of correction calling for retraining of emergency room employees on the requirements of the federal law and also the handling of "patients of size."
The report also cites the hospital for failure to maintain the required physician-on-call list.
Contact: wfrochejr999@gmail.com
A Clearfield County hospital has been cited for turning away a clearly distressed patient seeking care in the emergency room.
According to a report from the state Health Department the patient was told by a Penn Highlands Clearfield employee to go home and call for an ambulance. Ultimately an ambulance picked up the patient on the hospital grounds and then brought the patient to the emergency room.
In the report state Health Department surveyors cited a federal law, the Emergency Medical Treatment and Labor Act, which requires that a hospital with an emergency room must provide a prompt examination and treatment.
The hospital "failed to ensure that a medical screening examination was provided for one patient who presented to the emergency room," the report states.
The incident occurred on May 18 at 12:42 p.m. when the patient, accompanied by a relative, arrived at the hospital in the front passenger seat. The state surveyors reviewed hospital records and also viewed videotapes showing the patient's arrival.
"The patient was noted to be extremely upset, embarassed and crying," the report states, adding that the patient, who had suffered a fall, came to the hospital under a doctor's instructions.
"The patient was told by an employee they could not help because the patient was a fall risk," the report states.
Officials of the 50-bed hospital did not respond to requests for comment.
In addition to failing to make a required assessment of the patient, hospital employees failed to enter the patient's first visit into the emergency department log.
"The patient should have been entered into the log and then formally transferred," the report states.
The hospital filed a plan of correction calling for retraining of emergency room employees on the requirements of the federal law and also the handling of "patients of size."
The report also cites the hospital for failure to maintain the required physician-on-call list.
Contact: wfrochejr999@gmail.com
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