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Reports grim for Pennsylvania’s state-run veterans homes

In one state veterans home, health inspectors declared a state of imminent jeopardy because dementia patients wandered unattended in a dining area with potentially dangerous food and equipment.

In another facility, a veteran who pleaded to be sent to an emergency room because of excruciating pain was found dead on the floor of a heart attack.

Those incidents and dozens of others are recounted in grim detail in inspection reports for the six Pennsylvania-run veterans nursing homes.

The reports, compiled by state Health Department inspectors, show that despite outrage from veterans groups and patients’ families three years ago, the care provided often is lacking.

A spokeswoman for the state agency that runs the homes said all deficiencies were corrected.

“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.

In August, Daniel S. Monroe, 61, a Vietnam War veteran at the home in Hollidaysburg, begged to go to a hospital emergency room for treatment of his pain.

An unnamed physician refused the request and instead ordered new pain pills for Monroe. He had begun complaining of extreme pain at 3:40 p.m. Aug. 29, according to a Sept. 12 inspection report.

A nurse later told inspectors “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,” the report states. Instead, at 8:30 p.m., the on-call physician ordered a stronger medication.

Monroe died the following day at 12:45 a.m., says the report. His family could not be reached for comment.

The record shows he suffered from acute diverticulitis, “with associated partial bowel obstruction.” He had told nurses his pain was “worse than ever.”

“The resident was found on the floor in cardiac arrest,” according to the report. The incident received an “actual harm” rating 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 inspectors reviewed Monroe’s treatments during the two months before his death, they found other violations of state and federal rules because staffers failed to follow a physician’s medication orders.

A doctor had ordered they administer two pain tablets only when his pain was rated an 8 to 10 on a scale of 1 to 10. But he received two pills on multiple occasions without any indication that his pain had been assessed, the report stated. In other cases, he got two pills even with a pain rating of less than 8.

Officials at the Hollidaysburg facility promised to establish a policy that the medical director could override a physician’s orders. The plan of correction includes a monitoring system to ensure staffers follow orders.

Nissley said the unnamed physician in Monroe’s case continues to care for patients at Hollidaysburg.

An investigation by the Department of Military and Veterans Affairs concluded Monroe “did not pass away as a result of not receiving care,” Nissley said.

There was no indication his diagnosis was cardiac-related, she noted, and his “vital signs were stable” when the physician was notified.

Republican Sen. John Eichelberger, who represents Blair County, said he discussed the incident with Hollidaysburg officials. He is satisfied that veterans get good care at the facility. He blamed complaints about Monroe’s death on “employees who have an ax to grind.”

Eichelberger said he met with officials at the home when earlier abuse complaints surfaced. He determined they were unfounded.

At the Southeastern Veterans Home in Spring City, Chester County, a state inspector saw a diabetic dementia patient walk into a dining area, open a freezer and treat himself to a helping of ice cream.

Two dementia unit patients were seen later in the dining area, walking among steam tables that heat foods up to 140 degrees. The diabetic patient took a second helping of ice cream.

The inspector decided the situation placed 18 dementia patients in “immediate jeopardy” and ordered officials to take immediate action.

During that inspection of the 196-bed home, an inspector found a cart of medications unattended in a patient area.

The report cited officials’ failure to fully investigate possible abuse of a patient with an unexplained bruise. Nissley said that official was since replaced, and a new security system should prevent a recurrence. She said permanent gates now limit access to staff members.

At the Gino J. Merli Veterans Center in Scranton, inspectors found staff using powerful anti-psychotic drugs on Alzheimer’s and dementia patients, despite admonishments from regulators to curb use of such drugs.

Nissley said the number of patients receiving anti-psychotics has been reduced from 54 to 33 of the 193 residents, and the use of anti-psychotics is monitored at all the homes.

The Scranton facility reports show patients suffered worsening ulcers or bedsores because staffers did not monitor them properly. In one case late last year, no one performed required foot checks on a resident who had scabbing near his Achilles tendon. An inspector on Dec. 30 found no evidence of foot checks after Dec. 18.

Another resident, determined to be at risk for pressure sores when admitted, had developed multiple bedsores during his one-year stay.

The facility had been cited in an Oct. 24 Medicaid certification inspection for failing to prevent pressure sores or stop them from worsening. That report noted similar problems were found in earlier inspections. The citations led to a provisional license for the home.

The Southwestern Veterans Home in Pittsburgh was cited in a recent inspection for improper handling of bedding. And in a 2014 report, inspectors cited the home for giving an improper dose of insulin to a patient.

Walter F. Roche Jr. is a freelance writer for Trib Total Media. Reach him at [email protected].


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