By Walter F. Roche Jr.
A city-owned nursing home has been hit with two critical reports from state health surveyors who found the facility understaffed, dirty and with one patient out-of-control and injuring a fellow patient.
In two recent reports on the 402-bed Philadelphia Nursing Home, state Health Department inspectors found numerous deficiencies. The first report dated Dec. 9 specifically focused on staffing levels and found that on more than half the days reviewed the facility failed to maintain state mandated staffing levels.
While the state requires a facility to provide 2.7 hours of nursing care per patient per day the surveyors found that on 11 of 21 days reviewed the facility failed to meet that standard.
In the second report dated Jan. 10, surveyors concluded the facility "failed to maintain a clean and homelike environment for one of eight nursing units."
That second survey, which was conducted to determine whether the facility met federal Medicare and Medicaid standards, concluded that it didn't.
A clutter of trash was found next to one patient's bed and dried food was caked to a patient's wheelchair.
There was no care plan developed for three patients and proper incontinence care had not been provided to other patients. One of those patients told surveyors that when she pressed her call light for assistance, it was ignored.
The tracheotomy equipment for another patient was dirty and overdue for maintenance.
Other issues included "a mice problem" which one surveyor witnessed first hand and failure to arrange a psychiatric review for an Alzheimer's patient.
Another patient with psychiatric issues threw a bedside table at another patient. That patient was referred for a psychiatric review on Oct. 19 but did not get it until Nov. 12.
James Garrow, a city Health Department spokesman, said that the facility was holding job fairs and working with several different agencies in an attempt to fill vacant nursing home positions.
He said that current levels were at 3.38 hours of nursing care per patient per day, well above the state's minimum standards.
In it's plan of correction, which was accepted by the state, the nursing home reported it had cleaned up the clutter of trash and cleaned the food stained wheekchair.
The plan calls for audits to ensure care plans were developed for all patients. The overall plan also calls for psychiatric consults to be completed immediately and improvements in incontinence care.
Contact: wfrochejr999@gmail.com
Tuesday, February 22, 2022
Monday, February 7, 2022
Suicidal Patient Jumps to Death at Crozier
By Walter F. Roche Jr.
A shoeless psychiatric patient who had acknowledged having suicidal thoughts including plans to jump in front of an Amtrak train, was discharged unattended from an area hospital then climbed to an unsecured roof top access and jumped.
The fatal Nov. 16 incident at the Crozer Chester Medical Center was detailed in a recent 9-page report from the state Health Department.
"The facility failed to assist a patient at risk of suicide and failed to implement a plan to deal with withdrawal from alcohol," the report states.
The unnamed patient had been transported to the Upland hospital by an emergency medical team. He was rated as high risk for suicide after admitting to a plan to walk into a passing Amtrak train.
Asked if he had ever wished he was dead, the patient said, "Yes."
After being informed he was being discharged, the patient asked for shoes, but was told all of his belongings, including a wallet, had disappeared. When the hospital workers discovered they had no shoes that would fit him, he was given a second pair of socks.
Efforts to find a place in area shelter were unsuccesful.
When health department staffers reviewed the records they discovered a series of tests that should have been performed, but never were.
The facility failed to provide "a safe and detailed discharge," the report states.
The health department team also viewed surveillance videos shot during the discharge. "The last video shows the patient falling on the ground," the report states.
Crozer filed a plan of correction including new security measures to monitor the areas near the roof access point.
The plan also calls for the reassesment of patients for suicide risks and education of staffers, along with audits to ensure compliance.
The hospital did not respond to a series of questions about the incident and the state report.
Contact: wfrochejr999@gmail.com
A shoeless psychiatric patient who had acknowledged having suicidal thoughts including plans to jump in front of an Amtrak train, was discharged unattended from an area hospital then climbed to an unsecured roof top access and jumped.
The fatal Nov. 16 incident at the Crozer Chester Medical Center was detailed in a recent 9-page report from the state Health Department.
"The facility failed to assist a patient at risk of suicide and failed to implement a plan to deal with withdrawal from alcohol," the report states.
The unnamed patient had been transported to the Upland hospital by an emergency medical team. He was rated as high risk for suicide after admitting to a plan to walk into a passing Amtrak train.
Asked if he had ever wished he was dead, the patient said, "Yes."
After being informed he was being discharged, the patient asked for shoes, but was told all of his belongings, including a wallet, had disappeared. When the hospital workers discovered they had no shoes that would fit him, he was given a second pair of socks.
Efforts to find a place in area shelter were unsuccesful.
When health department staffers reviewed the records they discovered a series of tests that should have been performed, but never were.
The facility failed to provide "a safe and detailed discharge," the report states.
The health department team also viewed surveillance videos shot during the discharge. "The last video shows the patient falling on the ground," the report states.
Crozer filed a plan of correction including new security measures to monitor the areas near the roof access point.
The plan also calls for the reassesment of patients for suicide risks and education of staffers, along with audits to ensure compliance.
The hospital did not respond to a series of questions about the incident and the state report.
Contact: wfrochejr999@gmail.com
Monday, January 31, 2022
Patients at State Veterans Home Assaulted
By Walter F. Roche Jr.
Four patients at a state run nursing home for veterans were assaulted verbally or physically when officials of the Scranton facility failed to take action to restrain an assaultive fellow patient.
The incidents at the Gino Merli Veterans Center were detailed in a recent report from the state Health Department which noted that the attacks resulted in actual physical injury including a fractured finger and lacerations and contusions.
In one of the attacks the attacking patient punched another patient who was seated in his wheelchair, knocking him to the floor.
The patient was found lying on the floor, bleeding from a lip laceration and suffering from elbow lacerations.
The patient was later found to have a fractured pinky and required stitches for the mouth wounds.
Questioned about the attack, the victim said, "I was punched in the face by a man with white hair. My wheel chair fell over with me in it."
Surveyors from the health agency reviewed video tapes which confirmed the unprovoked attack.
Yet another victim was punched with a closed fist, the report states. Video of the incident showed the victim was punched five times.
The aggressor was sent to another facility for an evaluation, but was returned to the nursing home before the end of the day.
The final victim was subjected to expletive laced verbal abuse.
"The facility failed to ensure that four patients were free from physical and/or verbal abuse," according to the Dec. 3 report.
The nursing home's managers were also faulted for barring patients from having any visitors even after federal officials lifted a visitors' ban.
The facility filed a plan of correction in which officials said the assaultive patient was kept away from his victims. They also said the visitors ban was lifted.
Officials of the state agency which runs the veterans homes did not respond to questions about the report.
Contact: wfrochejr999@gmail.com
Four patients at a state run nursing home for veterans were assaulted verbally or physically when officials of the Scranton facility failed to take action to restrain an assaultive fellow patient.
The incidents at the Gino Merli Veterans Center were detailed in a recent report from the state Health Department which noted that the attacks resulted in actual physical injury including a fractured finger and lacerations and contusions.
In one of the attacks the attacking patient punched another patient who was seated in his wheelchair, knocking him to the floor.
The patient was found lying on the floor, bleeding from a lip laceration and suffering from elbow lacerations.
The patient was later found to have a fractured pinky and required stitches for the mouth wounds.
Questioned about the attack, the victim said, "I was punched in the face by a man with white hair. My wheel chair fell over with me in it."
Surveyors from the health agency reviewed video tapes which confirmed the unprovoked attack.
Yet another victim was punched with a closed fist, the report states. Video of the incident showed the victim was punched five times.
The aggressor was sent to another facility for an evaluation, but was returned to the nursing home before the end of the day.
The final victim was subjected to expletive laced verbal abuse.
"The facility failed to ensure that four patients were free from physical and/or verbal abuse," according to the Dec. 3 report.
The nursing home's managers were also faulted for barring patients from having any visitors even after federal officials lifted a visitors' ban.
The facility filed a plan of correction in which officials said the assaultive patient was kept away from his victims. They also said the visitors ban was lifted.
Officials of the state agency which runs the veterans homes did not respond to questions about the report.
Contact: wfrochejr999@gmail.com
Saturday, January 29, 2022
Monday, January 24, 2022
Meaness, Elopements Cited at Montgomery Facility
By Walter F. Roche Jr.
"There's a lot of meanness here," a patient at a Montgomery County nursing home told a surveyor from the Pennsylvania Health Department during a recent visit.
That encounter plus evidence of multiple violations of state requirements were detailed in a Nov. 10 report on the Meadow View Rehabilitation and Nursing Center in Lafayette Hill just feet away from the Philadelphia city line.
The inspectors found that the facility failed to properly investigate an incidents in which two disabled patients were able to walk out the door apparently unnoticed.
The patient who reported the "meanness," told the state employees he was barked at when he asked permission to leave his unit. He was advised not to ask again.
The surveyors found and observed several violations of infection control requirements in wards set up to treat patients who had contracted Covid-19 or had been in contact with someone who had the virus.
Employees were observed serving meals in the Covid-19 area without masks or protective equipment. Others were observed without the proper masks.
Employees told the inspectors that at one point in the midst of the pandemic there were no masks or protective gear available.
In other findings the records for a diabetic patient showed the physican overseeing care was not informed when blood/sugar levels skyrocketed.
In addition the facility had failed to set any goals or interventions for the patient.
"The patient complained his blood/sugar levels were not checked as required before an insulin injection," the report states.
Finally the report states that three smoking patients were not properly monitored and one patient's records were inaccurate.
Facilty officials did not respond to questions about the report. They did file a plan of correction with the state health agency. Under the plan officals of the 244-bed facility said housekeeping issues had been resolved and the nurse who yelled at a patient was instructed on the proper way to address a patient. The plan noted that the two patients who eloped were uninjured. Contact: wfrochejr999@gmail.com
"There's a lot of meanness here," a patient at a Montgomery County nursing home told a surveyor from the Pennsylvania Health Department during a recent visit.
That encounter plus evidence of multiple violations of state requirements were detailed in a Nov. 10 report on the Meadow View Rehabilitation and Nursing Center in Lafayette Hill just feet away from the Philadelphia city line.
The inspectors found that the facility failed to properly investigate an incidents in which two disabled patients were able to walk out the door apparently unnoticed.
The patient who reported the "meanness," told the state employees he was barked at when he asked permission to leave his unit. He was advised not to ask again.
The surveyors found and observed several violations of infection control requirements in wards set up to treat patients who had contracted Covid-19 or had been in contact with someone who had the virus.
Employees were observed serving meals in the Covid-19 area without masks or protective equipment. Others were observed without the proper masks.
Employees told the inspectors that at one point in the midst of the pandemic there were no masks or protective gear available.
In other findings the records for a diabetic patient showed the physican overseeing care was not informed when blood/sugar levels skyrocketed.
In addition the facility had failed to set any goals or interventions for the patient.
"The patient complained his blood/sugar levels were not checked as required before an insulin injection," the report states.
Finally the report states that three smoking patients were not properly monitored and one patient's records were inaccurate.
Facilty officials did not respond to questions about the report. They did file a plan of correction with the state health agency. Under the plan officals of the 244-bed facility said housekeeping issues had been resolved and the nurse who yelled at a patient was instructed on the proper way to address a patient. The plan noted that the two patients who eloped were uninjured. Contact: wfrochejr999@gmail.com
Thursday, December 23, 2021
PA Hospital Failed to Follow-up on Patient's Covid-19
This story was updated on Dec. 25 with comments from a hospital spokesman
By Walter F. Roche Jr.
A 188-bed Pennsylvania hospital failed to properly follow-up when a behavioral patient was diagnosed with Covid-19 five days after his admission.
In a 10-page report just made public this week, the state Health Department concluded that staff at the Allegheny Valley Hospital failed to provide adequate surveillance and take needed preventative action when the patient was diagnosed with Covid-19 on Oct. 25.
The unnamed patient was admitted on Oct. 21 and developed a fever on Oct. 24, the eve of his Covid-19 diagnosis.
After examining hospital records, the state inspectors concluded that in the days before the diagnosis, the patient had spent some 18 hours in the behavioral unit's hallway and six hours in the dayroom. He also spent more than 15 minutes with other patients while eating lunch.
Nonetheless hospital officials at the Natrona Heights hospital had concluded that none of the thirteen patients in the unit were at risk. No tests were administered, those officials concluded, because all of patientse tested negative at the time of admission.
The surveyors said a hospital employee who was involved in the followup to the diagnosis was unable to provide any documentation showing that contact tracing was completed.
In addition hospital employees told the health agency's surveyors that the conclusion that there was no risk of significant exposure was based on interviews but they were unable to name those purportedly interviewed. Finally a hospital employee (Employee 9) "admitted that contact tracing was not thorough."
The state surveyor also reported that they personally observed Allegheny Valley employees without proper masking.
In its plan of correction hospital officials said staff were re-educated on proper contact tracing procedures and that audits would be performed to ensure adherence.
The hospital said top infection control offficial met on Nov. 2 and "developed a comprehensive plan for identifying, reporting, investigating and preventing infections of communicable diseases" including Covid-19.
Dan Laurent, a hospital spokesman, said the hospital was preparing a more complete plan of correction which is expected to be filed with the state within a few days.
He added that the hospital had self reported the incident to state health official and informed the patient of what happened.
Contact: wfrochejr999@gmail.com
By Walter F. Roche Jr.
A 188-bed Pennsylvania hospital failed to properly follow-up when a behavioral patient was diagnosed with Covid-19 five days after his admission.
In a 10-page report just made public this week, the state Health Department concluded that staff at the Allegheny Valley Hospital failed to provide adequate surveillance and take needed preventative action when the patient was diagnosed with Covid-19 on Oct. 25.
The unnamed patient was admitted on Oct. 21 and developed a fever on Oct. 24, the eve of his Covid-19 diagnosis.
After examining hospital records, the state inspectors concluded that in the days before the diagnosis, the patient had spent some 18 hours in the behavioral unit's hallway and six hours in the dayroom. He also spent more than 15 minutes with other patients while eating lunch.
Nonetheless hospital officials at the Natrona Heights hospital had concluded that none of the thirteen patients in the unit were at risk. No tests were administered, those officials concluded, because all of patientse tested negative at the time of admission.
The surveyors said a hospital employee who was involved in the followup to the diagnosis was unable to provide any documentation showing that contact tracing was completed.
In addition hospital employees told the health agency's surveyors that the conclusion that there was no risk of significant exposure was based on interviews but they were unable to name those purportedly interviewed. Finally a hospital employee (Employee 9) "admitted that contact tracing was not thorough."
The state surveyor also reported that they personally observed Allegheny Valley employees without proper masking.
In its plan of correction hospital officials said staff were re-educated on proper contact tracing procedures and that audits would be performed to ensure adherence.
The hospital said top infection control offficial met on Nov. 2 and "developed a comprehensive plan for identifying, reporting, investigating and preventing infections of communicable diseases" including Covid-19.
Dan Laurent, a hospital spokesman, said the hospital was preparing a more complete plan of correction which is expected to be filed with the state within a few days.
He added that the hospital had self reported the incident to state health official and informed the patient of what happened.
Contact: wfrochejr999@gmail.com
Tuesday, December 21, 2021
Hospital Used Contaminated Testing Gear
By Walter F. Roche Jr.
A Pennsylvania hospital used contaminated gear for on internal test on an unsuspecting patient, according to a report from the state health department.
The report on Forbes Hospital, the second critical one to be released on the hospital in a matter of days, states that the same endoscope was used on a second patient without having been properly cleaned and processed.
In addition the state surveyors found that the incident was not "thoroughly investigated." The report states the facility "failed to ensure infection prevention processes were followed to prevent the potential contamination," the report states.
"Because of the foreign object inside the scope, the scope should be considered contaminated," the state health surveyors wrote in the report. The report does not indicate whether or not the patient exposed to the contaminated instrument was later found to be infected. A review of hospital records showed a letter informing the patient of what happened was not sent until Oct. 28, more than a week after the error was discovered.
In addition to the problem with the endoscope the inspectors found that a filter on equipment used in the cleaning process for storage of the endoscope had not been replaced at the proper intervals.
In fact, the report states, a worker who used the equipment was not even aware that it had a filter.
The hospital did not file an acceptable plan of correction and hospital officials did not respond to questions about the Oct. 20 incident.
In another recent report the 171-bed Monroeville hospital was faulted for letting a Covid-19 positive wait two hours in an emergency room before being seen.
Hospital officials did not respond to a request for comment.
Contact: wfrochejr999@gmail.com
A Pennsylvania hospital used contaminated gear for on internal test on an unsuspecting patient, according to a report from the state health department.
The report on Forbes Hospital, the second critical one to be released on the hospital in a matter of days, states that the same endoscope was used on a second patient without having been properly cleaned and processed.
In addition the state surveyors found that the incident was not "thoroughly investigated." The report states the facility "failed to ensure infection prevention processes were followed to prevent the potential contamination," the report states.
"Because of the foreign object inside the scope, the scope should be considered contaminated," the state health surveyors wrote in the report. The report does not indicate whether or not the patient exposed to the contaminated instrument was later found to be infected. A review of hospital records showed a letter informing the patient of what happened was not sent until Oct. 28, more than a week after the error was discovered.
In addition to the problem with the endoscope the inspectors found that a filter on equipment used in the cleaning process for storage of the endoscope had not been replaced at the proper intervals.
In fact, the report states, a worker who used the equipment was not even aware that it had a filter.
The hospital did not file an acceptable plan of correction and hospital officials did not respond to questions about the Oct. 20 incident.
In another recent report the 171-bed Monroeville hospital was faulted for letting a Covid-19 positive wait two hours in an emergency room before being seen.
Hospital officials did not respond to a request for comment.
Contact: wfrochejr999@gmail.com
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