By Walter F. Roche Jr.
Two patients at a Pittsburgh hospital died while being held in restraints and the facility failed to properly and timely report the deaths to government agencies.
The incidents at UPMC Mercy were disclosed in an investigative report recently made public by the health agency.
The critical eight-page report states that in three of nine cases reviewed the patients were not being properly monitored.
UPMC officials did not respond to questions about the report.
In one death case the hospital filed a report with a federal government agency indicating that the death occurred after the restraints were removed. Patient records, however showed the patient died while still in restraints.
The hospital filed a plan of correction in which they promised that staff involved with restraints would be re-educated on the proper use of restraints and the state and federal reporting requirements.
Contact: wfrochejr999@gmail.com
Tuesday, March 22, 2022
Monday, March 21, 2022
Missing Monitor Proves Deadly
By Walter F. Roche Jr.
The failure to attach a monitor to a critically ill patient ended with the death of the patient at a Philadelphia area hospital, according to a report from the state Health Department.
In a report on a complaint investigation at the Jefferson-Lansdale Hospital, state surveyors said the patient was found unresponsive and lifeless and without the cardiac monitor that had been ordered by a hospital physician hours earlier.
"The patient expired," the report states.
"Attempts at resuscitation were not succesful." In interviews hospital employees acknowledged the monitor was ordered, "It just was not implemented."
Due to the finding the state surveyors on Jan. 26 declared a state of "immediate jeopardy", forcing hospital officials to come up with an immediate written response.
The hospital came up with a plan to immediately notify responsible employees of the requirement to place monitors on patients immediately or within an hour of their arrival. The "immediate jeopardy" declaration was lifted at 7:12 p.m.
Hospital officials, however, did not file an acceptable plan of correction with the state Health Department and did not respond to a reporter's request for comments.
After reviewing hospital records, the inspectors concluded, "It was determined that a registered nurse failed to follow a physician's order to place a telemetry monitor for cardiac monitoring."
Contact:wfrochejr999@gmail.com
The failure to attach a monitor to a critically ill patient ended with the death of the patient at a Philadelphia area hospital, according to a report from the state Health Department.
In a report on a complaint investigation at the Jefferson-Lansdale Hospital, state surveyors said the patient was found unresponsive and lifeless and without the cardiac monitor that had been ordered by a hospital physician hours earlier.
"The patient expired," the report states.
"Attempts at resuscitation were not succesful." In interviews hospital employees acknowledged the monitor was ordered, "It just was not implemented."
Due to the finding the state surveyors on Jan. 26 declared a state of "immediate jeopardy", forcing hospital officials to come up with an immediate written response.
The hospital came up with a plan to immediately notify responsible employees of the requirement to place monitors on patients immediately or within an hour of their arrival. The "immediate jeopardy" declaration was lifted at 7:12 p.m.
Hospital officials, however, did not file an acceptable plan of correction with the state Health Department and did not respond to a reporter's request for comments.
After reviewing hospital records, the inspectors concluded, "It was determined that a registered nurse failed to follow a physician's order to place a telemetry monitor for cardiac monitoring."
Contact:wfrochejr999@gmail.com
Monday, March 7, 2022
Critical Patient's Care Delayed 82 Minutes
By Walter F. Roche Jr.
Emergency care for a "difficult" but critically ill patient was delayed one hour and 22 minutes at a Pittsburgh hospital ending in that patient's death.
Details of the December incident at the West Penn Hospital were recently made public in a 10-page report from the state Health Department. It concluded that the facility, part of the Allegheny Health Network, failed to protect the patient from neglect.
The report cites fellow hospital employees who concluded that the employees involved in the unnamed elderly patient's care were guilty of "gross misconduct."
The victim, who was recovering from severe burns over much of his body, had been a patient at the 317-bed hospital since July 31, but on Dec.20 his condition began to deteriorate with a sharp and sudden drop in his blood pressure.
Though the "acute change" was noted by one of the attending nurses, a doctor was not immediately notified, the report states.
An emergency reponse was finally triggered 82 minutes later when a second blood pressure drop triggered a Code Blue, but the patient remained pulseless and could not be revived. He was declared dead at 12:45 a.m. Dec. 11.
The report by state Health Department surveyors was apparently triggered by a complaint, but the source of the complaint was not disclosed.
Hospital officials failed to filed an acceptable plan of correction as required by state statutes and regulations and did not respond to requests for comment. The two employees blamed for the delayed care remained on the job, entrusted with the care of other patients, for 16 days while an internal investigation was conducted, according to the report.
At the end of that investigation, the report states, the two unnamed employees were terminated.
"The employees were union covered ... and were permitted to work in the same capacity during the investigation," the report states.
The surveyors' report indicates the delay in care was attributable, at least in part, to the fact that the patient was regarded by the staff as "difficult."
Citing the statements from another employee, the report states that "staff made a bad judgement and understood what staff failed to do but found the patient to be difficult." Relatives of the deceased patient did not respond to requests for comment.
The report states that in addition to suffering second and third degree burns over much of his body, the patient had also under gone an amputation during his extended treatment.
Contact: wfrochejr999@gmail.com
Emergency care for a "difficult" but critically ill patient was delayed one hour and 22 minutes at a Pittsburgh hospital ending in that patient's death.
Details of the December incident at the West Penn Hospital were recently made public in a 10-page report from the state Health Department. It concluded that the facility, part of the Allegheny Health Network, failed to protect the patient from neglect.
The report cites fellow hospital employees who concluded that the employees involved in the unnamed elderly patient's care were guilty of "gross misconduct."
The victim, who was recovering from severe burns over much of his body, had been a patient at the 317-bed hospital since July 31, but on Dec.20 his condition began to deteriorate with a sharp and sudden drop in his blood pressure.
Though the "acute change" was noted by one of the attending nurses, a doctor was not immediately notified, the report states.
An emergency reponse was finally triggered 82 minutes later when a second blood pressure drop triggered a Code Blue, but the patient remained pulseless and could not be revived. He was declared dead at 12:45 a.m. Dec. 11.
The report by state Health Department surveyors was apparently triggered by a complaint, but the source of the complaint was not disclosed.
Hospital officials failed to filed an acceptable plan of correction as required by state statutes and regulations and did not respond to requests for comment. The two employees blamed for the delayed care remained on the job, entrusted with the care of other patients, for 16 days while an internal investigation was conducted, according to the report.
At the end of that investigation, the report states, the two unnamed employees were terminated.
"The employees were union covered ... and were permitted to work in the same capacity during the investigation," the report states.
The surveyors' report indicates the delay in care was attributable, at least in part, to the fact that the patient was regarded by the staff as "difficult."
Citing the statements from another employee, the report states that "staff made a bad judgement and understood what staff failed to do but found the patient to be difficult." Relatives of the deceased patient did not respond to requests for comment.
The report states that in addition to suffering second and third degree burns over much of his body, the patient had also under gone an amputation during his extended treatment.
Contact: wfrochejr999@gmail.com
Tuesday, February 22, 2022
City Nursing Home Has Staffing Woes
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
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
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
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