Vets Home Charged with Neglect

By Walter F. Roche Jr. A paraplegic under treatment in a state run veterans nursing home in Pittsburgh, PA. was left sitting on a bedpan for two days and suffered a pressure ulcer and other injuries as a result, according to a report by state health surveyors. The report, just recently released, charges the facility with neglect for not only leaving the veteran helpless on a bedpan for two days but also for failing to provide a shower and other sanitary care services. The unnamed patient at the Southwestern Veterans Center in Pittsburgh suffered actual harm due to a bedpan being left underneath him and peri-care not being completed, the report states. "The facility failed to make certain that a resident was free from neglect," the report states. After examining the nursing homes records on a July 12 visit to the 236-bed facility, the surveyors found that the male patient was placed on a special bedpan on June 10 and was found on July 12 in the same situation. A staffer who examined him at 6:30 a.m. on June 12 described a reddened area approximately 24.5 centimeters in diameter and 1.5 centimeters thick. The patient had an "unstageable pressure ulcer" and "injury to the sacrum" with the bedpan being a contributing factor. The patient remained on the bedpan even though he was supposed to be turned and repositioned periodically to prevent bedsores. Interviews with several staffers involved in the patient's care acknowledged to state surveyors that the bedpan was not removed until June 12. The report states that additionally the patient was not provided with needed peri-care over the two day period. The inspectors also cited the center for failing to develop a comprehensive care plan for the same patient. The facility filed a plan of correction reported the patient's care was being re-assessed and wound care was being provided. They also promised to re-assess the needs of other residents who needed to be repositioned. The plan also includes staff retraining by Affinity Health Services.The plan calls for the corrective actions to be in place by Sept. 1 Asked to comment on the report, Joan Nissley, spokeswoman for the Department of Military and Veterans Affairs said,"The Bureau ensures that the provision of quality health care for our Veteran residents and their spouses is delivered in a caring and dignified manner while ensuring compliance with all appropriate state and federal regulations." Posted by Walter Roche at 1:27 PM No comments: Email ThisBlogThis!Share to TwitterShare to FacebookShare to Pinterest

Patients Injured at Scranton Vets' Home

By Walter F. Roche Jr.

Residents at a Scranton, PA veterans nursing home suffered bone fractures and other injuries when workers at the facility failed to follow doctors' orders, according to a report from the state Health Department.
In a lengthy report recently made public, inspectors from the health agency also cited the Gino J. Merli Veterans Center for multiple violations of state and federal laws and regulations. The 196-bed facility has been cited for similar infractions in several previous state reviews.
According to the report, one patient suffered bruises and a broken collarbone in a fall from a wheelchair, while another broke a bone in his hand when he was left unattended and fell from his bed.
In another case a patient, who was supposed to be under close monitoring, wandered out of the home undetected, jumped a fence only to be spotted crossing a local street.
The home "failed to provide sufficient staff" to prevent accidents for three patients and the elopement of a fourth, the inspection report states
Officials from the state Department of Military and Veterans Affairs filed a corrective action plan with the Health Department in which they promised to take numerous steps to avoid recurrences.
Agency spokeswoman Joan Nissley said the plan of correction was accepted by state health officials and has already been implemented.
Nissley said additional staffers have been hired for the Scranton facility but not in response to the inspection report.
"When areas of concern are identified, we take immediate action to address and rectify them, with a continued focus on the safety and care of residents," Nissley said.
The patient who fell from his bed "required extensive assistance from two staffers for bed mobility, dressing and transfer," the inspection report states, nonetheless a single worker was present at the time of the incident.
The patient was left sitting at the edge of his bed when the aide left him to adjust the bed. The resident fell and suffered a broken bone in his hand and a facial laceration, according to the report.
A second resident who was severely cognitively impaired was left sitting in a wheelchair. He nodded off and fell, fracturing his collarbone.
Yet a third patient fell when workers "failed to follow" his care plan.
The resident who wandered out of the home did so on Dec. 17 of last year. A device that would sound an alarm if he attempted to leave the building had been removed earlier in the day because he was no longer at risk for elopement.
Though he was still supposed to be closely monitored, he left the facility undetected at 4:17 p.m..
Footage from a surveillance camera showed he jumped a fence and left the area. By chance a home worker on a coffee break at a local store spotted him crossing a street. He was brought back to the home unharmed and told workers he wanted to go see his wife.
Other items cited in the report include the failure to make residents aware of grievance procedures and failing to document that narcotic drugs were actually administered to patients. While the facility records showed a licensed practical nurse retrieved the drugs from a supply area, there was no documentation that the pills were actually delivered to the patient as required.
The report states that home management "failed to ensure that nursing services met professional standards of quality" and failed to ensure the accurate administration of narcotic medications for five of 29 residents.
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Two Pa Veterans Homes Cited for Violations

By Walter F. Roche Jr.

Two of the six Pennsylvania run nursing homes for veterans have been found out of compliance with the minimum standards required for participation in the federally financed Medicare and Medicaid programs.
In detailed inspection reports recently posted on the state Health Department's web site, the violations were found at the 339-bed Hollidaysburg Veterans Center in Blair County and the 238 bed Southeast Veterans Center in Chester County.
Joan Nissley, spokeswoman for the state Department of Military and Veterans Affairs, which runs the homes, said that corrective action plans to address the deficiencies have been implemented and accepted by the state Health Department.
"We remain committed to providing quality long-term care for Pennsylvania's veterans and their spouses in a safe, secure and caring environment," Nissley stated, adding that she could not comment on specific personal patient care.
The report on the Chester County facility cites multiple cases of patients falling and sustaining injuries because staffers did not assist them as ordered in their medical records.
The facility "failed to ensure that adequate monitoring, supervision and implementation of interventions were provided to prevent falls and injuries," the report states.
A female resident was found to have suffered a hip fracture when staffers responded to her calls for help on March 18 of this year.
"Resident was ambulating unassisted and with no supervision," the report states.
Another patient's fall resulted in multiple areas of bleeding on the brain.
"The licensed staff failed to follow the resident's plan of care," the report states.
Yet another patient suffered a head laceration from a fall in January. That same patient suffered from falls on May 30, Aug. 17 and Aug. 24, the report states.
Another patient diagnosed with hypertension and dementia had five falls between April and October of this year.
"The facility failed to provide resident B7 with appropriate supervision during ambulation to prevent falls," the inspectors reported.
Other deficiencies reported at the Chester county facility included failing to properly store medications and discard expired medications.
In several cases the inspectors found that staffers failed to inform the patients' physicians when tests were missed or adverse test results had been recorded.
There were medication errors including the case of a patient who had ear drops mistakenly placed in the eye.
The report on the Hollidaysburg home included details of patients being transported on wheelchairs without leg rests, thus placing them at risk for injuries.
One patient was observed with his legs bouncing up and down while being taken out of the dining area.
The report states that the facility had failed to perform an assessment to determine "if it was safe" to transport the patients in wheelchairs without leg rests.
In an October case, the inspectors found that staffers failed to thoroughly investigate the cause of bruising on a patient's arm.
Another patient who required oxygen was observed with an empty tank.
In February a patient was discovered with two pairs of scissors impaled on his abdomen. The inspectors noted that a day before that discovery a strong odor had been detected in the patient's room but it was not reported or investigated.
"When areas of concern are identified, we take immediate action to address and rectify them, with a continued focus on the safety and care of residents," Nissley said, noting that all six homes are fully licensed.
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VA Whistleblower Suit Revived

By Walter F. Roche Jr.

A federal appeals court has reversed a lower court ruling and given new life to a whistle-blower suit alleging that a company with long time ties to former Veterans Affairs Secretary Anthony J. Principi defrauded the agency under a contract to provide medical exams.
The ruling by a three judge panel of the 9th Circuit Court of Appeals reverses a U.S. District Court ruling dismissing the claims filed by David Vatan, a former employee of the contractor QTC Medical Services.
The lower court had dismissed Vatan's claims contending he failed to provide the court with a detailed copy of QTC Medical's contract with the Veterans Administration.
Formerly a subsidiary of Lockheed Martin, QTC was once headed by Principi. The former VA Secretary subsequently registered as a lobbyist for QTC-Lockheed. QTC was eventually sold to Leidos, Inc
The appeals court ruled that the False Claims Act does not require that Vatan file an exact copy of the VA contract.
"Where, as here, the relevant information is within the defendant's exclusive possession and control such pleading is sufficient," the court said referring to the details in the Vatan complaint.
It added that if the standards set by the district court were to be applied to all False Claims Act suits, it would "vitiate the False Claims Act by excluding many whistle-blowers, who, as here, allege insider knowledge of wrongdoing that few others would be positioned to reveal."
The appeals court also concluded that speculation by the district court on possible elements of the contract was irrelevant.
"The specific contractual language and any contemplated error rate in the contract are immaterial to whether this claim is adequately pleaded," the ruling states.
Vatan "alleges that QTC essentially lied to the government as to whether files were reviewed," it continues.
The court concluded that Vatan's allegations "are specific enough to give defendants notice of the particular misconduct. He therefore successfully alleges that QTC misrepresented what goods or services it provided to the federal government."
Vatan's original suit charged that QTC required its employees to process so many claims for Agent Orange injuries in such a short time, it was impossible for them to complete a thorough examination.
Lawyers for QTC denied the allegations.

VA Probe Confirms Long Wait List, Manipulation

By Walter F. Roche Jr.

An internal  investigation has confirmed that the Veterans Administration facility in Pittsburgh had 700 veterans waiting for appointments in 2014 and that staffers routinely manipulated data to hide the actual number of veterans facing unacceptable delays.
In a 22 page report on its probe of the allegations, the VA's Inspector General said it confirmed media reports that more than 700 veterans were on a New Enrollee Appointment Request (NEAR) list in May of 2014.
The "Administrative Summary" of the probe was made public late last week.
In addition after interviewing some 40 current and former employees and reviewing emails and other records, the IG found widespread evidence that staffers were manipulating data to hide the fact that veterans were not getting appointments within acceptable 30 day time periods.
In fact some staffers reported being told to make it appear that a veteran had no wait at all.
"Medical Support Assistant (MSA)  #1 confirmed he had been directed to schedule appointments in a manner that did not accurately reflect accurate wait times," the report states.
A former senior leader told investigators "it was her understanding that MSAs were being directed to manipulate appointment entries so that it appeared that performance standards were met when in reality standards were not being met."
According to the report some current and former staffers interviewed said they were not aware of any wait time manipulation. In some of those cases, however, investigators found emails and other evidence showing the same staffers did alter data despite the denials.
According to the report, a supervisor said "she became aware of a way to reset the 30-day time frame for scheduling appointments so that they did not exceed the 30 day requirement.
Another staffer said "she shortened wait times on her appointment only because those above her wanted her to do it.
Yet another staffer reported that she shortened wait time about 20 times from December of 2013 to March of 2014.
The cause of the lengthy delays, according to the report, were multiple and ranged from a shortage of medical professional to a logjam when a single staffer was assigned to set appointments for all veterans on the NEAR list.
The IG also looked into but did not confirm allegations that some staffers were given bonuses as a reward for manipulating data. The data showed one service chief received more than $45,000 in extra pay.

TB Case at VA Pittsburgh, PA

By Walter F. Roche Jr.

An unidentified veteran who has been a patient at Veterans Affairs facilities in the Pittsburgh area has been diagnosed with tuberculosis and is undergoing treatment.
VA Pittsburgh officials disclosed Wednesday that the patient was diagnosed Monday and is responding well to treatment. He has been a patient at the VA outpatient facility in Beaver County and the University Drive facility in Pittsburgh.
According to an announcement from the VA, no additional cases have been found but the agency is now notifying persons who may have come into contact with the ailing veteran and offering free testing. That process is expected to take several days, according to VA officials.
"While it is unlikely anyone potentially exposed will become ill, out of an abundance of caution we urge notified patients and employees to be tested, " VA Medical Director Karin McGraw said in a statement.
Tuberculosis is transmitted through the air and symptoms include coughing up blod, chest pain, fever, chills and night sweats.

Two PA Veterans Homes Cited in Sexual Assaults

By Walter F. Roche Jr.

Two state run veterans homes have been cited by the Pennsylvania Health Department for incidents in which female residents were sexually assaulted by male patients.
The incidents, one at the Hollidaysburg Veterans Home and the second at the Gino J. Merli Veterans Center in Scranton, triggered citations for violations of state law and regulations.
The two facilities, which have been the subject of several other critical inspection reports, are part of the state Department of Military and Veterans Affairs, which operates six such facilities statewide.
A third home, the Southwestern Veterans Home in Pittsburgh, was cited recently for an incident in which a veteran was seriously injured while being transported in a wheelchair. The home's license was put on a provisional basis as a result of the inspection.
Joan Nissley, a department spokeswoman, said the incidents at the Scranton and Hollidaysburg facilities "sparked a wide-ranging, multidisciplinary review that is still ongoing."
Asked if any employees were disciplined following the  incidents, Nissley said that while she could not comment on any specific personnel matter "we can state that appropriate disciplinary actions have been taken where applicable."
Nissley said there are 28 female patients at the Scranton home and 46 at Hollidaysburg. Overall 13 percent of all state veterans home residents are female.
At the Hollidaysburg Veterans Home a male resident, who had previously assaulted a female patient, entered that same female patient's room on Aug. 21 and pulled down her pants and touched her genitals then began masturbating.
A staffer saw the male patient leaving the female's room with his pants unzipped and his genitals exposed.
According to the report the female patient was bruised and had slight bleeding. She was sent to a hospital for an examination.
The female resident, the report continues, "was scared and very upset." She said she didn't ring the call button because she was scared
The Health Department report noted that following the incident officials at the home did not interview other female residents to ask whether they had ever been sexually assaulted.
The same male resident had assaulted the same female patient in April, the report states. He squeezed her breast two times on April 22 when she was seated in her wheelchair in a hallway.
Following that incident, staffers were advised to keep the male resident away from the female, the report states, but "there was no documented evidence that following the April 22 incident, the staff monitored Resident 1 (the male) when he was around female residents."
The 15-page report also faults the Blair County home for failing "to provide sufficient detail about a resident incident to the Department of Health regarding an incident which seriously compromised a resident's safety."
In a plan of correction, Hollidaysburg officials said the male patient had been moved to an all male unit and was to undergo a psychiatric evaluation. The victim was provided supportive counseling and a psychiatric evaluation.
The plan also includes training of staff on dealing with sexual behaviors. Other residents were evaluated for any inappropriate sexual behaviors, according to the plan.
Officials at the Scranton veterans home were cited for failing to monitor a patient who had a history of inappropriate sexual behavior. The patient was supposed to have 1 to 1 monitoring during waking hours but early in the morning of July 23 the staffer assigned to watch the male patient left to attend to another patient.
The employee, the report states, did not ask another staff member to observe the male resident even though he had been observed in the hallway near the female patient's room.
"The facility failed to ensure that Resident 28 (the female) was kept safe from Resident 1's unwanted sexual behavior," the report states.
According to the report the staffer who left to attend another patient "was immediately removed from the nursing unit.
In addition the facility was cited for failing to report the incident to the state Department of Aging, as required by law.
Notification was provided however, to local police and the Area Agency on Aging.
In its plan of correction, the facility formally notified the area agency of the incident and said it would audit all abuse allegations
At the Southwestern Veterans Center in Pittsburgh a patient was injured when he fell headfirst on the floor causing a forehead gash requiring 18 stitches.
The aide had failed to apply leg rests to the wheelchair as ordered and when the wheelchair hit a threshold the patient pitched forward striking the floor.
In its corrective action plan the facility reported it re-evaluated the injured patient and the need for leg rests. The plan also includes evaluating all other wheel chair bound patients for the need for leg rests.
Nissley said the agency's "number one priority is ensuring that our veterans and their spouses receive long term care in a safe and secure and caring environment."
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