Category Archives: Immediate Jeopardy

Chicago Hospital Ordered to Pay More than $10 Million Dollars to a Female Doctor and 6 Nurses who Filed a Lawsuit for Two Separate Harassment Incidents Including Being Choked by a Doctor, and Another Doctor who installed a Toilet Cam in the Women’s Locker Room

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RISKAlert  Report #1073                                      Sept. 19, 2018                                       Chicago, Illinois

The former employees of Advocate Illinois Masonic Medical Center in Chicago won a lawsuit against the
hospital after reporting that hospital doctors harassed them.  The Chicago Tribune reported that the hospital received
reports about violent incidents but did nothing.  The women accused the hospital of failing to act when violations of the hospital own written policies were reported and then ignored. 

$7 million of the total amount was awarded to Dr. Caroline Ryan, an anesthesiologist who was choked and
pushed by Dr. Stephen F. Laga, in 2013. The attack was witnessed by several hospital staff members
and also by patients.  Dr. Ryan was asked by hospital administration to drop her report against Laga, who
had a “long and documented” history of violent behavior, says the complaint.   Laga was never disciplined.

The following year, a hidden camera was found on the toilet (Potty Cam?) in the women’s locker room where
women changed clothes and used the restroom.  The camera was planted by Dr. Robert Weiss, an eye surgeon
at Illinois Masonic, who viewed and possibly shared the content. Weiss was arrested when the camera was
discovered. Although aware of his arrest, the hospital delayed suspending Weiss’ medical privileges.

The women’s complaint also pointed out that the hospital had ignored previous reports of inappropriate
sexual behavior from Weiss.  The six women were awarded $1.75 million for violations of their privacy and
an additional $2 million for punitive damages. “The jury was sending a clear message”, said the women’s
attorney, Jeffrey Kulwin.  He said he believes doctor misconduct has been tolerated because of the money the
doctors bring in to the hospitals.

“Today’s verdict against Advocate sends a strong message to Advocate, and employers everywhere,
that violence in the workplace cannot be tolerated, especially at a place as important as a hospital,”

LESSONS LEARNED:

1.  Having, and Enforcing a strong policy against workplace violence and harassment is a critical
     component of creating a safe workplace, no matter who is being violent against others!

2.  The hospital lost the lawsuit because they blatantly refused to enforce their OWN POLICIES! 

THANKS FOR READING THE RISKAlert Report©

For more information write to:  caroline@riskandsecurityllc.com
We provide the best Facility Risk Assessments, as well as Active Shooter Assessments, Training,
Workplace  Violence Assessments, and  & CMS All Hazards Risk Assessments, Facility Drills &  Training.

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#RiskAssessment                                       #CMSImmediateJeopardy                                       #HospitalViolence

NURSING HOME MAY LOSE CMS MEDICARE FUNDING AFTER RESIDENT IGNITED OXYGEN TANK WHILE SMOKING, CAUGHT FIRE AND BURNED FOR 10 MINUTES

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RISKAlert Report Updated:  July 5, 2018                                                                                           Helena, Montana

NURSING HOME MAY LOSE CMS MEDICARE FUNDING AFTER RESIDENT  IGNITED OXYGEN TANK WHILE
SMOKING, CAUGHT  FIRE AND BURNED FOR TEN MINUTES

Montana’s Health Department recently found that a Helena nursing home was neglecting patients, after an unsupervised resident smoking a cigarette on oxygen caught on fire and suffered second-degree burns in May.  The resident died several weeks later.  The facility had a new non-smoking policy in place.

As part of a CMS Survey, the Montana Department of Public Health &Human Services conducted a survey of Big Sky Healthcare Community after receiving a complaint about the facility. The survey found that the Helena facility neglected the resident when she was outside unsupervised on May 1.

The resident was on fire for approximately 10 minutes before staff reached her and called emergency medical services, according to a witness.  The survey also found the facility failed to report the incident, various staff members were unclear on the facility’s smoking policies and some residents were inappropriately left to administer their own medications.

The CMS Survey classified the incident as an “immediate jeopardy” situation, meaning the facility had to take immediate corrective actions to protect residents or risk losing its Medicare and Medicaid certification.  Big
Sky Healthcare successfully removed the immediate risk while the state workers were on site. The facility later had to submit a detailed corrective action plan to address all of the issues identified by the state.

The resident, who is not named in the report, was caught smoking multiple times by staff in the months prior to catching on fire. The resident came to the facility in December 2017 with a lung disease that restricts breathing and required supplemental oxygen.  The resident was burned on May 1, admitted to hospice on May 8 and died on May 24, according to the report.

A staff member said the facility’s policy required nurses to keep cigarettes and lighters stored away from patients, but nurses don’t enforce that. The staff member said management was aware nurses were not enforcing the policy. Another staff member said residents were allowed to keep cigarettes and lighters in their rooms.

LESSONS LEARNED:

  1. Nursing home residents should never be allowed to smoke. Policies should be adjusted to
    reflect this, and staff should be trained on how to report infractions.
  2. If residents are unfortunately allowed to smoke, They should be under constant supervision and
    oxygen tanks should be far away from the resident.


THANKS FOR READING THE RISKAlert Report©

For more information and a free subscription:  write to:  caroline@riskandsecurityllc.com 
We provide the best Active Shooter and Facility Risk Assessments & Training Programs.
Find out more at   www.riskandsecurityllc.com .

Western State Hospital (Tacoma, WA), Could Lose $65 Million in Federal Funds as CMS Finds Serious Risk for Exposed Fire System Devices that could be used by Patients to Commit Suicide by Hanging

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RISKALERT  #1040 – Report Updated:  May 30, 2018

In a memo sent to top staff earlier in the week, “CMS identified a serious risk of harm to patients due to ligature risks
from the fire system in patient care areas of Building 21 ,” said the memo, which was obtained by public radio. Building 21 is where civil, or non-criminal, patients are treated on five different wards. Typically a ward has 30 patients. Western State Hospital is a Psychiatric Residential Treatment Center (PRTC) with over 800 beds.

A CMS finding of serious risk of harm is also known as an “immediate jeopardy.”  The memo also said that if the issue is not resolved, funding could be lost in 23 days.

Since 2015, Western State Hospital has been under scrutiny for serious repeat violations that inspectors said put patients and staff at risk. The litany of troubles included violent assaults on patients and staff, the 2016 escape of two high-risk patients and scores of unauthorized patient “walkaways.”

The safety violations were discovered by a team of 22 federal surveyors who were re-inspecting the hospital last week as part of a turnaround plan that is approaching the two-year mark. The sprawling hospital, which serves civil and forensic patients, must meet standards on 26 federal “Conditions of Participation” in order to continue receiving federal funding.

A “root cause” report in 2016 identified ineffective management, staff reductions and turnover leading to patients who felt “neglected” and a “culture of helplessness” among staff. A review by the Department of Corrections also found numerous security gaps including 25,000 master keys unaccounted for.

LESSONS LEARNED

1.   CMS requires all residential treatment facilities to maintain a safe physical environment, and any
identified risk situations should be addressed immediately to prevent loss of CMS reimbursement funds..

  1.  Management must take the lead even in facilities related issues, instead of leaving the improved
    implementations up to lower level staff members.

    THANKS FOR READING THE RISKAlert Report    ©For more information and a free subscription:  write to:  caroline@riskandsecurityllc.com

    We provide the best Active Shooter Training, Workplace Violence Assessments, and & CMS Facility All-
    Hazards  Risk   Assessments, Drills &  Training Programs.

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