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Making Hepatitis History Part 6: Shocking stories hiding in inspection records

Making Hepatitis History Part 6: Shocking stories hiding in inspection records

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When you first start a health beat, visit the licensing agency for all the health facilities in your area. It will give you a great story or two out of the gate. It also will initiate a work pattern that should yield many great stories in the years to come.

Every medical facility – hospital, clinic, nursing home, psychiatric center – that receives federal funding is subject to licensing and inspection. States have their own licensing requirements and often perform their own inspections, usually on behalf of the feds. Luckily, the standard form for these inspections is the federal 2567.

On a 2567, inspectors log their findings from regular licensing reviews and from complaints about safety and health violations.

I should say "deficiencies." That's officialspeak for violations, and it is a term you will see over and over again in the inspection reports, which are titled "statements of deficiencies."

A deficiency can be anything from malfunctioning equipment to a borderline homicide, although it is not always obvious when a patient has died.

Reporters have used them to document patterns of medication errors, nursing lapses and management failures. They also have used them to describe a particularly outrageous case of negligent care.

By law, the health facility must make these inspection reports available, but it is often easier to ask the agency for copies or, as I suggested above, go to the agency's office and look at the forms themselves. Every state does things a little differently. California collects all of its recently completed reports on its Web site. It also allows you to review all administrative penalties by county.

The form is divided in half. On the left are the problems, or deficiencies, the inspectors found. On the right are the health facility's responses, known as the "plan of correction."

The first draft of the report won't include the plan of correction, and you want to make sure your copy includes the plan.

If you find a report that interests you, file a request for the back-up investigative notes, which can shed even more light on what went wrong.

This can be crucial because the 2567s can be maddeningly vague, a far cry from the details found in the report the Southern Nevada Health District wrote about the Endoscopy Center of Southern Nevada. There is no difference in tone between citations that involve patient deaths and those in which no one was injured. In fact, the reports sometimes fail to mention patient deaths. The deaths are likely to show up in the investigative notes.

Last week, David Gambacorta at the Philadelphia Daily News used a hospital inspection report to describe, in cringe worthy detail, the death of popular local musician Joaquin Rivera in the waiting room of Aria Health's hospital in Frankford.

Rivera, 63, entered the hospital's emergency department at 10:45 p.m. and complained of pain on his left side.  According to the report, surveillance footage showed that Rivera stopped moving at 10:56 p.m.

Seven minutes later, a hospital staffer told state investigators, she called Rivera's name and noticed that he was staring at a wall.

According to the state report, no hospital personnel checked to see if Rivera was in need of medical help.

The emergency department "triage nurse appeared at the patient waiting room door entrance and did not enter . . . between 10:45 p.m. and 11:47 p.m." to check on patient activity, the report shows.

Hospital staffers became aware of Rivera's condition only when another patient alerted them.

By that time, Rivera was already dead, and had been robbed by three vagrants who stole his wristwatch.

A beloved local musician left for dead and robbed in an ER lobby without anyone bothering to check on him? It's hard to find a story much better than that in a government document.

Related posts:

Making Hepatitis History Part 1: Michael Jackson's deadly drug strikes again

Making Hepatitis History Part 2: Sterilization logs can help uncover medical negligence

Making Hepatitis History Part 3: Bankruptcy court holds dirty secrets little and large

Making Hepatitis History Part 4: Time stamps can separate medical fact from fiction

Making Hepatitis History Part 5: Purchasing records reveal painful penny pinching

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