At
one state veterans home health inspectors declared a state of imminent jeopardy as dementia patients were observed wandering unwatched and undetected in a dining area with potentially dangerous food and equipment.
At another facility, a 61-year-old Vietnam veteran who had pleaded to be sent to an emergency room because of excruciating pain was found dead on the floor of a heart attack.
Those incidents coupled with dozens of others are recounted in grim detail in inspection reports for the six Pennsylvania run veterans nursing homes stretching from Erie to Pittsburgh and on to Philadelphia.
The reports, compiled by inspectors from the Pennsylvania Health Department, show that despite outrage from veterans groups and the families of patients just three years ago, the care being provided to veterans in these facilities is often lacking.
A spokesman for the state agency which runs the homes said in response to questions that all the deficiencies were corrected as soon as they were brought to its attention.
"Our priority is always to provide superior care to all of our residents across the state and when deficiencies are identified, we take quick corrective action," said Joan Nissley, the spokeswoman.
It was in late August of last year at the veterans home in Hollidaysburg that the Vietnam veteran began pleading to be sent to a hospital emergency room because of excruciating pain.
An unnamed physician, however, refused the request, instead ordering new pain pills for the 61-year-old.
According to the Sept. 12, 2014 inspection report, the patient began complaining of extreme pain at 3:40 p.m. on Aug. 29.
Citing a subsequent interview with a nurse, the report states that the patient was "in excruciating pain at the time he requested to go to the emergency room. She (the nurse) indicated that the resident had symptoms that warranted a transfer to the emergency room, but because she did not receive an order from the physician, the resident was not sent."
Instead, at 8:30 p.m., the five-page report states, the on-call physician ordered a stronger pain medication.
"A nursing note dated Aug. 30, 2014 at 12:45 a.m. revealed that the patient ceased to breathe," according to the inspection report.
The records show that veteran was suffering from acute diverticulitis "with associated partial bowel obstruction." He had told the nursing staff his pain was "worse than ever."
"The resident was found on the floor in cardiac arrest," the health official reported. The incident was given the rating of, "actual harm," under federal inspection guidelines. The Blair County facility was cited for multiple violations of state and federal rules, including failure to respond to the patient's wishes.
When the state inspection team looked back at the patient's treatment record in the two months preceding his death, they found other violations of state and federal rules because staffers failed to follow a physician's medication orders.
Although the doctor had ordered that two pain tablets be administered only when his pain was rated between eight and ten on a scale of one to ten, two pills had been administered on multiple occasions without any indication that the patient's pain had been assessed. In other cases two pills were administered even with a pain rating of less than eight.
As required under state and federal law, officials at the Hollidaysburg facility filed a plan of correction in which they promised to establish a system under which a physician's orders could be overridden by the medical director.
The plan of correction also includes a monitoring system to ensure that physicians' orders are being followed.
Nissley said that the unnamed physician is still employed at Hollidaysburg and is currently caring for patients.
"Resident CR1 is no longer a resident at the facility," the corrective action plan states.
Records show that Daniel S. Monroe died early in the morning of Aug. 30 at the Hollidaysburg facility. He was 61. His family could not be reached for comment.
At the Southeastern Veterans Home in Spring City Chester County, a state inspector observed a diabetic dementia patient walk into a dining area, open a freezer and then treat himself to a helping of ice cream.
Later two dementia unit patients were observed in the same dining area walking among steam tables used to heat foods up to 140 degrees. The diabetic patient took a second helping of ice cream.
The inspector then declared that the situation placed as many as 18 dementia patients in "immediate jeopardy" and ordered home officials to take immediate corrective action.
On the same inspection of the 196-bed home, an inspector observed a cart full of medications open and unattended in a patient area.
Also cited in the report was the failure of the top home official to fully investigate the possible abuse of a patient who suffered an unexplained bruise. Nissley said that official has since been replaced and a new security system will prevent a recurrence
At the Gino J. Merli Veterans Center in Scranton, inspectors found that despite admonishments from federal and state regulators to curb the use of powerful antipsychotic drugs on patients suffering from Alzheimer's disease or dementia those drugs were being used with no attempt to even reduce the dosage.
Nissley said the use of antipsychotics has since been reduced at the Scranton facility and monitoring programs have been put in place at the other five veterans homes.
At another facility, a 61-year-old Vietnam veteran who had pleaded to be sent to an emergency room because of excruciating pain was found dead on the floor of a heart attack.
Those incidents coupled with dozens of others are recounted in grim detail in inspection reports for the six Pennsylvania run veterans nursing homes stretching from Erie to Pittsburgh and on to Philadelphia.
The reports, compiled by inspectors from the Pennsylvania Health Department, show that despite outrage from veterans groups and the families of patients just three years ago, the care being provided to veterans in these facilities is often lacking.
A spokesman for the state agency which runs the homes said in response to questions that all the deficiencies were corrected as soon as they were brought to its attention.
"Our priority is always to provide superior care to all of our residents across the state and when deficiencies are identified, we take quick corrective action," said Joan Nissley, the spokeswoman.
It was in late August of last year at the veterans home in Hollidaysburg that the Vietnam veteran began pleading to be sent to a hospital emergency room because of excruciating pain.
An unnamed physician, however, refused the request, instead ordering new pain pills for the 61-year-old.
According to the Sept. 12, 2014 inspection report, the patient began complaining of extreme pain at 3:40 p.m. on Aug. 29.
Citing a subsequent interview with a nurse, the report states that the patient was "in excruciating pain at the time he requested to go to the emergency room. She (the nurse) indicated that the resident had symptoms that warranted a transfer to the emergency room, but because she did not receive an order from the physician, the resident was not sent."
Instead, at 8:30 p.m., the five-page report states, the on-call physician ordered a stronger pain medication.
"A nursing note dated Aug. 30, 2014 at 12:45 a.m. revealed that the patient ceased to breathe," according to the inspection report.
The records show that veteran was suffering from acute diverticulitis "with associated partial bowel obstruction." He had told the nursing staff his pain was "worse than ever."
"The resident was found on the floor in cardiac arrest," the health official reported. The incident was given the rating of, "actual harm," under federal inspection guidelines. The Blair County facility was cited for multiple violations of state and federal rules, including failure to respond to the patient's wishes.
When the state inspection team looked back at the patient's treatment record in the two months preceding his death, they found other violations of state and federal rules because staffers failed to follow a physician's medication orders.
Although the doctor had ordered that two pain tablets be administered only when his pain was rated between eight and ten on a scale of one to ten, two pills had been administered on multiple occasions without any indication that the patient's pain had been assessed. In other cases two pills were administered even with a pain rating of less than eight.
As required under state and federal law, officials at the Hollidaysburg facility filed a plan of correction in which they promised to establish a system under which a physician's orders could be overridden by the medical director.
The plan of correction also includes a monitoring system to ensure that physicians' orders are being followed.
Nissley said that the unnamed physician is still employed at Hollidaysburg and is currently caring for patients.
"Resident CR1 is no longer a resident at the facility," the corrective action plan states.
Records show that Daniel S. Monroe died early in the morning of Aug. 30 at the Hollidaysburg facility. He was 61. His family could not be reached for comment.
At the Southeastern Veterans Home in Spring City Chester County, a state inspector observed a diabetic dementia patient walk into a dining area, open a freezer and then treat himself to a helping of ice cream.
Later two dementia unit patients were observed in the same dining area walking among steam tables used to heat foods up to 140 degrees. The diabetic patient took a second helping of ice cream.
The inspector then declared that the situation placed as many as 18 dementia patients in "immediate jeopardy" and ordered home officials to take immediate corrective action.
On the same inspection of the 196-bed home, an inspector observed a cart full of medications open and unattended in a patient area.
Also cited in the report was the failure of the top home official to fully investigate the possible abuse of a patient who suffered an unexplained bruise. Nissley said that official has since been replaced and a new security system will prevent a recurrence
At the Gino J. Merli Veterans Center in Scranton, inspectors found that despite admonishments from federal and state regulators to curb the use of powerful antipsychotic drugs on patients suffering from Alzheimer's disease or dementia those drugs were being used with no attempt to even reduce the dosage.
Nissley said the use of antipsychotics has since been reduced at the Scranton facility and monitoring programs have been put in place at the other five veterans homes.
Reports for the same facility show
a pattern of patients suffering worsening ulcers or bed sores after
staffers failed to follow required monitoring procedures on patients at risk for ulcers.
In one case late last year required foot checks were apparently not performed on a resident who already had scabbing near his Achilles tendon.
The inspector who visited the facility on Dec. 30, noted that there was no evidence that a foot check had been performed after Dec. 18.
Another resident who had been identified as being at risk for pressure sores at the time of his admission was found to have developed multiple bed sores during his one-year stay.
The facility already had been cited in an Oct. 24, 2014 Medicaid certification inspection for failing to take steps to prevent pressure sores and to stop existing sores from worsening. As that report noted similar problems were noted in still earlier inspections.
As a result of the citations the home was issued only a provisional license.
The Southwestern Veterans Home in Pittsburgh was cited in a recent inspection for the improper handling of bedding. In a report in 2014 inspectors cited the home for giving an improper dose on insulin to a patient.
In one case late last year required foot checks were apparently not performed on a resident who already had scabbing near his Achilles tendon.
The inspector who visited the facility on Dec. 30, noted that there was no evidence that a foot check had been performed after Dec. 18.
Another resident who had been identified as being at risk for pressure sores at the time of his admission was found to have developed multiple bed sores during his one-year stay.
The facility already had been cited in an Oct. 24, 2014 Medicaid certification inspection for failing to take steps to prevent pressure sores and to stop existing sores from worsening. As that report noted similar problems were noted in still earlier inspections.
As a result of the citations the home was issued only a provisional license.
The Southwestern Veterans Home in Pittsburgh was cited in a recent inspection for the improper handling of bedding. In a report in 2014 inspectors cited the home for giving an improper dose on insulin to a patient.
