Multiple Violations at TN Veterans Home

By Walter F. Roche Jr.

Significant medication errors and failure to follow doctors orders were just two of multiple violations turned up in an August Medicare inspection of the Hollidaysburg Veterans Center,a state owned 257-bed nursing home in Blair County.
The just-released 27-page report from the state Health Department concluded that the facility did not meet the minimum requirements of the federal Medicare program.
"The facility failed to ensure residents received care and treatment in accordance with professional standards of practice," the report states.
Home officials submitted a corrective action plan which is being implemented, but officials of the state Department of Military and Veterans Affairs, which runs the six state-owned veterans homes did not respond to a series of questions about the report.
The medication errors cited included the case of a heart patient who was prescibed digoxin but only if his heart rate was within prescribed parameters. A review of records showed the patient was given the drug multiple times when his pulse rate was not within the precribed range.
In addition facility records showed the patient's physician was not informed of those "significant" errors.
In another case cited in the report a patient diagnosed with multiple sclerosis suffered a deep tissue injury in the leg caused by a brace a doctor prescribed. However a consultant at the facility had concluded the brace should be removed.
The consultant's recommendation was never passed along to the doctor and the patient continued to wear the brace and then suffered the deep tissue injury.
"There was no documented evidence that the orthopedic clinic was notified about the new wound or the request for the brace to be removed until it (the wound) healed," the report states.
Still other issues raised by the state surveyors include the lack of assistance provided to a resident whose hearing aid was lost during transfer to the Covid area and the inexplicable decision to deprive some patients of metal eating utensils.
The surveyors witnessed a staffer failing to follow infection control procedures in caring for a patient suffering from scabies and another patient was observed with his catheter bag dragging on the floor. Contact: wfrochejr999@gmail.com