By Walter F. Roche Jr.
One of the facilties in a six hospital system has been cited for keeping an autistic patient in restraints for some 32 days between late last year and early this year.
In a 22-page report made public last week, state Health Department investigators concluded the Penn Highlands Hospital at Huntingdon failed to limit admissions to its behavioral unit to patients it was capable of providing needed care.
The patient had a history of autism spectrum, intellectual disability and bipolar disorder, according to the report.
A review of records at the 71-bed facility showed the unnamed patient was kept in restraints for 32 days after displaying violent, self destructive behavior.
The facility "failed to ensure needed communication assistance was provided" to the patient who spoke little and gave one word answers.
Though the patient had in the past made some progress with visual icons, there was no record that they were utilized in dealing with the patient.
The facility failed "to ensure a patient received dignified care at all times," according to the report.
The report states that there was no documentation that the patient was re-assessed face-to-face every eight hours while in restraints.
"When a hospital provides psychiatric services, it shall be provided in a manner sufficient to meet the patient's needs," the report states, adding that a facility should limit admissions to those it is capable of providing needed care for.
Toileting problems with the unnamed patient were reported and in one instance the patient got off the toilet and charged at the staff.
"There was no documentation the patient had been offered toileting. There was no documentation of incontinence," the report states.
"We do not have the staff," one hospital employee told the state surveyors, adding that "Multiple people are needed for the care of this patient and one person can't handle this patient."
The facility also failed to develop an individualized treatment plan for the patient and failed to ensure that physician consults for possible surgery were implemented.
In a plan of correction filed with the state the hospital said it would re-educate staff on the use of restraints, admission requirements and the rights and responsibilities of patients. Hospital officials did not respond to a series of questions about the report.
Contact: wfrochejr999@gmail.com
Sunday, May 30, 2021
Tuesday, May 25, 2021
M-Care Violations at Surgical Hospital
By Walter F. Roche Jr.
An outpatient surgical center co-owned by some of the most prestigous medical facilities in the Philadelphia region has been cited for failing to report eight serious events in which patients had to be transferred to another facility.
The Physicians Care Surgical Hospital in Royersford had to transfer the patients when they experienced a variety of conditions ranging from hypoxia to atrial fibrillation. The transfers, which the state considers "serious events" were not reported to the state Health Department or the Patient Safety Authority.
The 30,000 square foot facility, located in western Montgomery County, is co-owned by the Rothman Institute, Main Line Health, Jefferson Health and NueHealth, an operator of physician owned health facilities.
The report, which was recently made public, was based on a full licensure survey conducted by the state Health Department.
The report states that the failure to report the eight patient transfers violated the state Medical Care Availability and Reduction of Error Act, known as M-Care.
"Serious events must be reported within 24 hours of their discovery," the report states, adding that the facility should transfer any patient who's presenting medical conitions the facility is not equipped to handle.
Three of the patients had to be transferred after EKG changes. Another was transerred due to "malignant hypertension."
Other violations of state requirements included the failure to establish a separate patient safety committee.
In fact the hospital was using one committee to fulfill state requirements for separate panels, including an infection control committee.
Still other violations including sanitation problems in the food preparation area, dusty areas in some of the 12 patient rooms and an operating room.
When a state investigator asked about the dirty cover on a trash can in an operating room, an employee offered a quick explanation.
"That's probably blood. We did a joint replacement in here this morning and the blood just sprays."
The facility did not file an acceptable plan of correction with the state and hospital officials did not respond to questions.
Contact: wfrochejr999@gmail.com
An outpatient surgical center co-owned by some of the most prestigous medical facilities in the Philadelphia region has been cited for failing to report eight serious events in which patients had to be transferred to another facility.
The Physicians Care Surgical Hospital in Royersford had to transfer the patients when they experienced a variety of conditions ranging from hypoxia to atrial fibrillation. The transfers, which the state considers "serious events" were not reported to the state Health Department or the Patient Safety Authority.
The 30,000 square foot facility, located in western Montgomery County, is co-owned by the Rothman Institute, Main Line Health, Jefferson Health and NueHealth, an operator of physician owned health facilities.
The report, which was recently made public, was based on a full licensure survey conducted by the state Health Department.
The report states that the failure to report the eight patient transfers violated the state Medical Care Availability and Reduction of Error Act, known as M-Care.
"Serious events must be reported within 24 hours of their discovery," the report states, adding that the facility should transfer any patient who's presenting medical conitions the facility is not equipped to handle.
Three of the patients had to be transferred after EKG changes. Another was transerred due to "malignant hypertension."
Other violations of state requirements included the failure to establish a separate patient safety committee.
In fact the hospital was using one committee to fulfill state requirements for separate panels, including an infection control committee.
Still other violations including sanitation problems in the food preparation area, dusty areas in some of the 12 patient rooms and an operating room.
When a state investigator asked about the dirty cover on a trash can in an operating room, an employee offered a quick explanation.
"That's probably blood. We did a joint replacement in here this morning and the blood just sprays."
The facility did not file an acceptable plan of correction with the state and hospital officials did not respond to questions.
Contact: wfrochejr999@gmail.com
Tuesday, May 18, 2021
Hospital Handcuffed Behavioral Patient
By Walter F. Roche Jr.
A Johnstown hospital not only had a policy allowing for the use of handcuffs on patients, it used that policy to handcuff an unruly behavioral patient in mid-March.
A state Health Department investigative report states that the handcuff policy at the 436-bed Conemaugh Memorial Medical Center was "inconsistent" with federal regulations.
In the report dated March 24 state health surveyors found that on March 17, a nursing supervisor ordered the hospital's security staff to handcuff the patient, who had a history of disruptive behavior.
The supervisor ordered the cuffing "for the safety of the patient and nursing staff." In an interview with the state health investigators a hospital employee said that in the past the hospital had summoned the local police to subdue the patient.
"The patient's behavior escalated so quickly and was much stronger than ancticipated that we didn't have the time to wait for police," the hospital employee told the surveyors.
"So instead of tasing the patient I gave the order for security to handcuff the patient," the nursing supervisor told the state surveyors.
In its plan of correction the hospital said it had updated its policy to comply with the federal regulations and eliminate the "verbiage related to the use of handcuffs."
The plan also calls for two sessions per year with staff on the updated policy. Contact: wfrochejr999@gmail.com
A Johnstown hospital not only had a policy allowing for the use of handcuffs on patients, it used that policy to handcuff an unruly behavioral patient in mid-March.
A state Health Department investigative report states that the handcuff policy at the 436-bed Conemaugh Memorial Medical Center was "inconsistent" with federal regulations.
In the report dated March 24 state health surveyors found that on March 17, a nursing supervisor ordered the hospital's security staff to handcuff the patient, who had a history of disruptive behavior.
The supervisor ordered the cuffing "for the safety of the patient and nursing staff." In an interview with the state health investigators a hospital employee said that in the past the hospital had summoned the local police to subdue the patient.
"The patient's behavior escalated so quickly and was much stronger than ancticipated that we didn't have the time to wait for police," the hospital employee told the surveyors.
"So instead of tasing the patient I gave the order for security to handcuff the patient," the nursing supervisor told the state surveyors.
In its plan of correction the hospital said it had updated its policy to comply with the federal regulations and eliminate the "verbiage related to the use of handcuffs."
The plan also calls for two sessions per year with staff on the updated policy. Contact: wfrochejr999@gmail.com
Monday, May 17, 2021
Father Stepped In to Insert NG Tube
This story was updated on May 21 with comments from a hospital spokesman, Dan Laurent.
By Walter F. Roche Jr.
When a patient's family grew visibly irritated with the failed efforts of a hospital worker to place a nasogastric tube, the patient's father stepped in and, on the third try, placed the tube.
The incident occurred at the Allegheny General Hospital, according to a recently released report from the state Health Department, which cited the facility for allowing a non-credentialed physician to perform a procedure.
According to the five-page report dated April 5, an unidentified hospital employee made several failed attempts to insert the tube. The actual date of the incident was not included in the report.
"The patient's family was visibly agitated at the failed attmpts," the report states, adding "The patient's father, who is a physician, immediately said he would place the tube."
The report states that the unidentified hospital employee then handed the tube to the father, who then failed twice to insert the tube through the patient's right nostril. But after a break the father successfully inserted the tube.
"The tube had output of green bile," state health surveyors reported.
In an interview with the state investigators, an unidentified hospital employee acknowledged that the father was not credentialed to practice at Allegheny General.
"The facility failed to ensure an appointed and credentialed physician performed a procedure," the report stated.
The hospital filed a plan of correction in which it promised to educate the staff about the requirement that only credentialed physcians perform medical procedures at the facility.
In addition audits will be performed to ensure compliance.
Allegheny General spokesman Dan Laurent said the plan of correction had been fully implemented and accepted by the state. He noted the hospital self-reported the incident and there was no evidence of physical harm to the patient.
Contact: wfrochejr999@gmail.com
By Walter F. Roche Jr.
When a patient's family grew visibly irritated with the failed efforts of a hospital worker to place a nasogastric tube, the patient's father stepped in and, on the third try, placed the tube.
The incident occurred at the Allegheny General Hospital, according to a recently released report from the state Health Department, which cited the facility for allowing a non-credentialed physician to perform a procedure.
According to the five-page report dated April 5, an unidentified hospital employee made several failed attempts to insert the tube. The actual date of the incident was not included in the report.
"The patient's family was visibly agitated at the failed attmpts," the report states, adding "The patient's father, who is a physician, immediately said he would place the tube."
The report states that the unidentified hospital employee then handed the tube to the father, who then failed twice to insert the tube through the patient's right nostril. But after a break the father successfully inserted the tube.
"The tube had output of green bile," state health surveyors reported.
In an interview with the state investigators, an unidentified hospital employee acknowledged that the father was not credentialed to practice at Allegheny General.
"The facility failed to ensure an appointed and credentialed physician performed a procedure," the report stated.
The hospital filed a plan of correction in which it promised to educate the staff about the requirement that only credentialed physcians perform medical procedures at the facility.
In addition audits will be performed to ensure compliance.
Allegheny General spokesman Dan Laurent said the plan of correction had been fully implemented and accepted by the state. He noted the hospital self-reported the incident and there was no evidence of physical harm to the patient.
Contact: wfrochejr999@gmail.com
Monday, May 3, 2021
Hospital Cited in Newborn Death
By Walter F. Roche Jr.
A newborn baby died within hours of delivery after staff at the Crozer Chester Medical Center failed to respond promptly to three calls for emergency assistance by a nurse caring for the baby.
"The medical staff failed to respond in a timely manner for a patient in distress," according to a recently released 15-page report from the state Health Department.
The report cites the hospital, located in Delaware County, for failure to have in place a clear escalation policy to be implemented in the event a health care provider does not timely repond to an urgent request for assistance.
The incident began on Feb. 3 when nurses noted the baby that had not yet been delivered had a rapid heartbeat and moments later no heartbeat at all.
According to the state report, the first call went to a resident (CF1) who was actively involved in a delivery.
Despite subsequent calls to the standby resident (CF2), no physician came to assess the patient and her mother for some 45 minutes. The nurse was told CF2 was unavailable.
According to the report the mother, who was in her 22 second week of pregnancy, was admitted to the 424-bed Crozer Chester facility on Jan. 17 with prolonged rupture of membranes.
On Feb. 3 at 21:22 (9:22 p.m.) a nurse monitoring the mother and baby reported the child's heart was racing and then no heartbeat could be detected. The nurse called the on-call resident but was told the physician was in the operating room.
She called for a resident a second time and the second resident ordered fluid initiation and said he would make an assessment when the ongoing delivery was complete.
"At 21:27 (9:27 p.m.)the nurse noted the loss of a fetal heartbeat," the report states, adding that she then escalated the patient's condition and a colleague suggested she get a doppler to perform a sonogram.
A code pink was called at 22:00 (10 p.m.)and the infant was delivered by cesarean section 10 minutes later by the first resident.
According to the report, nurses and employees told state surveyors that the second resident was not in the operating room and not delivering a baby when the nurse tried to reach him and was told he was unavailable.
"Employee seven confirmed CF2 (the second resident) was not in a delivery at the time.
"The whole thing went on for 45 minutes to an hour," the hospital employee told state Health Department officials.
The same employee told the surveyors that there was no written hospital protocol on an "escalation process."
Following the delivery the infant was taken to the neo-natal intensive care unit and the child's condition deteriorated overnight. Death occurred just before 09:00 a.m. Feb. 4.
The hospital did file a plan of correction which included escalation protocols and staff education, but when a surveyor returned on March 15, neither had been initiated.
Hospital officials did not respond to a series of questions about the report.
Contact: wfrochejr999@gmail.com
A newborn baby died within hours of delivery after staff at the Crozer Chester Medical Center failed to respond promptly to three calls for emergency assistance by a nurse caring for the baby.
"The medical staff failed to respond in a timely manner for a patient in distress," according to a recently released 15-page report from the state Health Department.
The report cites the hospital, located in Delaware County, for failure to have in place a clear escalation policy to be implemented in the event a health care provider does not timely repond to an urgent request for assistance.
The incident began on Feb. 3 when nurses noted the baby that had not yet been delivered had a rapid heartbeat and moments later no heartbeat at all.
According to the state report, the first call went to a resident (CF1) who was actively involved in a delivery.
Despite subsequent calls to the standby resident (CF2), no physician came to assess the patient and her mother for some 45 minutes. The nurse was told CF2 was unavailable.
According to the report the mother, who was in her 22 second week of pregnancy, was admitted to the 424-bed Crozer Chester facility on Jan. 17 with prolonged rupture of membranes.
On Feb. 3 at 21:22 (9:22 p.m.) a nurse monitoring the mother and baby reported the child's heart was racing and then no heartbeat could be detected. The nurse called the on-call resident but was told the physician was in the operating room.
She called for a resident a second time and the second resident ordered fluid initiation and said he would make an assessment when the ongoing delivery was complete.
"At 21:27 (9:27 p.m.)the nurse noted the loss of a fetal heartbeat," the report states, adding that she then escalated the patient's condition and a colleague suggested she get a doppler to perform a sonogram.
A code pink was called at 22:00 (10 p.m.)and the infant was delivered by cesarean section 10 minutes later by the first resident.
According to the report, nurses and employees told state surveyors that the second resident was not in the operating room and not delivering a baby when the nurse tried to reach him and was told he was unavailable.
"Employee seven confirmed CF2 (the second resident) was not in a delivery at the time.
"The whole thing went on for 45 minutes to an hour," the hospital employee told state Health Department officials.
The same employee told the surveyors that there was no written hospital protocol on an "escalation process."
Following the delivery the infant was taken to the neo-natal intensive care unit and the child's condition deteriorated overnight. Death occurred just before 09:00 a.m. Feb. 4.
The hospital did file a plan of correction which included escalation protocols and staff education, but when a surveyor returned on March 15, neither had been initiated.
Hospital officials did not respond to a series of questions about the report.
Contact: wfrochejr999@gmail.com
Monday, April 26, 2021
Veteran in State Home Badly Injured
By Walter F. Roche Jr.
A dementia patient in a state veterans home was severely injured when he drank highly toxic drain cleaner that had been left unattended in a hallway by a maintenance worker at the facility.
According to a report from the state Health Department, the resident at the Southwest Veterans Center in Pittsburgh, drank from a bottle of Drain Rocket that had been left on a maintenance cart in the hallway of the home's dementia unit.
"The facility failed to make certain that residents were protected from an unsafe chemical," the report states. The resident was taken to the Veterans Hospital on Feb. 26 where he had to be placed in a chemically induced coma and intubated. He was still in the hospital when the March 5 health department report was written.
The chlorinated drain cleaner was highly toxic, the state surveyors reported. The patient, who had been diagnosed with non-Alzheimers dementia and depression, had been admitted to the 236-bed facility on Nov. 27, 2018 and had a long history of taking food from other patients' trays and stuffing it in his underwear and shoes.
"Resident is not able to be redirected or deterred from this behavior," the report states citing nursing home records.
"Resident becomes incredibly aggressive and agitated if staff members attempt to assist him to rid his clothing and chair of these collected items," according to report.
"Resident had several episodes of aggression towards staff," the report continues. Using surveillance footage the state surveyors were able to see the patient take the drain cleaner from the cart.
At 2:44 p.m., the report states, the patient took the bottle and drank from it. He immediately yelled for help and spat on the floor and later began to vomit.
He was taken to the Veterans Administration hospital where he was placed in a coma. According to the report the maintainence employee later acknowledged leaving the drain cleaner unsecured on his cart while he went into a patient's room.
Following the incident, employees of the nursing home made a sweep of the facility to find any other unsecured chemicals and maintenance carts were checked to make sure they were equipped with locked compartments where drain cleaner and other toxic chemicals could be secured, the report states.
In its plan of correction, the nursing home officials said a re-education program was instituted. A private firm, Affinity Health, was hired to conduct the training, according to the report.
Official of the state Department of Military and Veterans Affairs, which runs the state veterans homes, said patient confidentiality rules barred them from disclosing whether the injured veteran recovered.
Joan Nissley, an agency spokeswoman, said the corrective action plan had been fully implemented.
Contact: wfrochejr999@gmail.com
A dementia patient in a state veterans home was severely injured when he drank highly toxic drain cleaner that had been left unattended in a hallway by a maintenance worker at the facility.
According to a report from the state Health Department, the resident at the Southwest Veterans Center in Pittsburgh, drank from a bottle of Drain Rocket that had been left on a maintenance cart in the hallway of the home's dementia unit.
"The facility failed to make certain that residents were protected from an unsafe chemical," the report states. The resident was taken to the Veterans Hospital on Feb. 26 where he had to be placed in a chemically induced coma and intubated. He was still in the hospital when the March 5 health department report was written.
The chlorinated drain cleaner was highly toxic, the state surveyors reported. The patient, who had been diagnosed with non-Alzheimers dementia and depression, had been admitted to the 236-bed facility on Nov. 27, 2018 and had a long history of taking food from other patients' trays and stuffing it in his underwear and shoes.
"Resident is not able to be redirected or deterred from this behavior," the report states citing nursing home records.
"Resident becomes incredibly aggressive and agitated if staff members attempt to assist him to rid his clothing and chair of these collected items," according to report.
"Resident had several episodes of aggression towards staff," the report continues. Using surveillance footage the state surveyors were able to see the patient take the drain cleaner from the cart.
At 2:44 p.m., the report states, the patient took the bottle and drank from it. He immediately yelled for help and spat on the floor and later began to vomit.
He was taken to the Veterans Administration hospital where he was placed in a coma. According to the report the maintainence employee later acknowledged leaving the drain cleaner unsecured on his cart while he went into a patient's room.
Following the incident, employees of the nursing home made a sweep of the facility to find any other unsecured chemicals and maintenance carts were checked to make sure they were equipped with locked compartments where drain cleaner and other toxic chemicals could be secured, the report states.
In its plan of correction, the nursing home officials said a re-education program was instituted. A private firm, Affinity Health, was hired to conduct the training, according to the report.
Official of the state Department of Military and Veterans Affairs, which runs the state veterans homes, said patient confidentiality rules barred them from disclosing whether the injured veteran recovered.
Joan Nissley, an agency spokeswoman, said the corrective action plan had been fully implemented.
Contact: wfrochejr999@gmail.com
Monday, April 19, 2021
Reading Fireman Dies After Hour + Wait for MD
By Walter F. Roche Jr.
A veteran Reading, PA fireman, in highly critical condition from Covid-19, was kept waiting for over an hour before an emergency physician arrived at his bedside, but it was too late.
The victim, Mark Kulp, 52, died Jan. 5 at Penn State Health - Saint Joseph just as a chest tube was finally being inserted.
"The cardio-thoracic physician failed to arrive in a timely manner," states a report from the state Department of Health.
Though the state report only refers to Mark Kulp as MR1, Wanda Kulp, said the patient was her late husband, who had been admitted in late December and tested positive for Covid-19.
Wanda Kulp said that neither the state or Penn State Health had informed her of the report's completion or release.
She said the family was kept "waiting and waiting."
In fact the report was completed in early March and posted on the state Health Department web site last week. The department generally does not make such reports public until 41 days after their completion.
Penn State Health - Saint Joseph officials did not respond to questions about the report including whether any action was taken against the physician who arrived one hour and 23 minutes after an anesthetist had reported to the scene.
The report states that just as a breathing tube was being inserted, Kulp coded. "The medical staff failed to provide timely medical care to a patient in respiratory distress," according to the report.
The anesthetist had arrived at 5:25 a.m. The unamed cardio-thoracic physician arrived at 6:45 a.m., according to the report.
The tube placement began at 7:22 a.m., the time of Kulp's death.
In its plan of correction, which the state accepted, hospital officials said new policies and procedures were put in place to insure against any recurrence.
"On March 4, 2021, the determination was made that the hospital took sufficient action to ensure hospital staff had a mechanism to follow when a physician did not report in a timely manner to provide emergent patient care," the Health Department report states.
The call for emergency help came early on Jan. 5 when Kulp experienced worsening breathing problems. An intensive care physician ordered an X-Ray which showed a collapsed lung.
"The virtual ICU physician ordered intubation and placement of a chest tube," the report states.
The longtime fireman, Kulp had also worked as an EMT and had transported patients who were diagnosed with Covid-19. His death prompted a large procession from the hospital to a local funeral home with his wife riding on Engine 7, her husband's engine.
In addition to his wife, Kulp was survived by his mother, Louise Kulp, a daughter, Alyssa Luft, a brother, two sisters and two grandchildren.
Contact: wfrochejr999@gmail.com
A veteran Reading, PA fireman, in highly critical condition from Covid-19, was kept waiting for over an hour before an emergency physician arrived at his bedside, but it was too late.
The victim, Mark Kulp, 52, died Jan. 5 at Penn State Health - Saint Joseph just as a chest tube was finally being inserted.
"The cardio-thoracic physician failed to arrive in a timely manner," states a report from the state Department of Health.
Though the state report only refers to Mark Kulp as MR1, Wanda Kulp, said the patient was her late husband, who had been admitted in late December and tested positive for Covid-19.
Wanda Kulp said that neither the state or Penn State Health had informed her of the report's completion or release.
She said the family was kept "waiting and waiting."
In fact the report was completed in early March and posted on the state Health Department web site last week. The department generally does not make such reports public until 41 days after their completion.
Penn State Health - Saint Joseph officials did not respond to questions about the report including whether any action was taken against the physician who arrived one hour and 23 minutes after an anesthetist had reported to the scene.
The report states that just as a breathing tube was being inserted, Kulp coded. "The medical staff failed to provide timely medical care to a patient in respiratory distress," according to the report.
The anesthetist had arrived at 5:25 a.m. The unamed cardio-thoracic physician arrived at 6:45 a.m., according to the report.
The tube placement began at 7:22 a.m., the time of Kulp's death.
In its plan of correction, which the state accepted, hospital officials said new policies and procedures were put in place to insure against any recurrence.
"On March 4, 2021, the determination was made that the hospital took sufficient action to ensure hospital staff had a mechanism to follow when a physician did not report in a timely manner to provide emergent patient care," the Health Department report states.
The call for emergency help came early on Jan. 5 when Kulp experienced worsening breathing problems. An intensive care physician ordered an X-Ray which showed a collapsed lung.
"The virtual ICU physician ordered intubation and placement of a chest tube," the report states.
The longtime fireman, Kulp had also worked as an EMT and had transported patients who were diagnosed with Covid-19. His death prompted a large procession from the hospital to a local funeral home with his wife riding on Engine 7, her husband's engine.
In addition to his wife, Kulp was survived by his mother, Louise Kulp, a daughter, Alyssa Luft, a brother, two sisters and two grandchildren.
Contact: wfrochejr999@gmail.com
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