Three days ago, a story broke, that Carlisle Regional Medical Center (“CRMC”) had been taken to task by the Pennsylvania Department of Health. The article said two deaths in the Emergency Department may be blamed on dangerous understaffing.

I read the survey results on the DOH website, and it doesn’t look good for CRMC. Below are the lowlights, because I’m certain CRMC would not call them highlights.

The hospital did not, “provide high quality health care to ensure care was provided in a safe setting.” On a specific day, May 23, 2011, the ED had allowed at least one patient to wait sixteen hours before being taken to the med-surg service or the ICU. In this period, it was found the ED was down a nurse. Nurses in the ED complained to their supervisor, but no remedy was found. The following day, a similar situation occurred, again when the ED was one nurse short. The supervisor did not fix the staffing problem. The problems continued through June 3, 2011.

Despite the days of problems, the facility’s Emergency Department continued to accept patients, and did not send seriously ill people to a hospital that could provide appropriate care.

CRMC appears to have violated its own policy of moving patients to the proper service within thirty minutes of the order having been written.

In an interview, an unnamed source said, “When we tell administration they say we are out of control and troublemakers.” The doctors, who are temporarily hired in, do not know how to use the computer system and slow the work of the nurses. When a cardiac patient codes, requiring the full attention of the staff, there is a single nurse left to watch the trauma patients, and some of the cardiac monitors don’t work.

An unnamed employee stated, “The patients have a delay in treatment because of lack of staffing.” Part of the problem is that CRMC is not hiring. There were only two part-time nursing positions open in the other parts of the hospital. If the ICU nurses or the med-surg nurses are overwhelmed, and that is causing long hold times in the ED, it appears CRMC is doing nothing to fix the problem. Another quote from the survey: “Insufficient staff causing a backup in the ED.”

Hospital management was aware of serious understaffing, and “told the ED nurses to be more creative.” It appears the ED director was fired because of attempting to fix the understaffing problem.

Now to the specific cases that ended in patient deaths.

The Department of Health Survey says, “…the facility failed to ensure that the Emergency Department services were provided to meet the emergency needs of patients in accordance with acceptable standards of practice for two of two serious events reviewed.” Keep in mind, these are not my words, these are not the reporters words, these are words I’m copying from the survey done by Pennsylvania.

Incident: June 5, 2011. A patient triaged from the Emergency Department to Intensive Care Unit, taken to CT Scan from the ED, on the way back to ED, coded and died. Evidently, the patient went to the CT Scan without a nurse, as no nurses were available. When he became unresponsive, he was brought back to the ED for resuscitation. The patient coded after being in the ED for six hours. An unnamed employee said that at the time of the incident, the ED was full and the waiting room was full. It appears that the ED was short one RN and was at less than minimal staffing.

Incident: June 11, 2011. A cardiac patient was seen by a doctor who intended he would be transferred to another facility. The patient was diagnosed with critical aortic stenosis. He arrived at CRMC at approximately 11:14a.m., and still in the ED, passed away at 6:37p.m. A man with a serious heart problem and dramatic symptoms, stayed in the ED for almost seven hours. A doctor’s note, said the patient remained “in the emergency room due to staffing issues…” No order was ever written for a transfer to an outside facility. Department of Health officials reviewed a medical record, which they report said the following: “The ED was overwhelmed. Nurse patient ratio was 9:1, 6:1, and 7:1. The triage nurse was taking patients and unable to answer call bells. IV pumps were unavailable. There were delays in getting beds and delays in patients being evaluated by MD. A code occurred and the patient died.” On the day of the incident, the ICU was full and management was aware of the situation.

After these events, the hospital did not even follow the simple duty of reporting the serious incident to the state, as required by law. An unnamed employee told the state investigators that death on the way back from the CT scanner met the facility’s own definition of a serious event, which should have been reported. No kidding. CRMC’s patient safety officer was not informed of the event. Similarly, unnamed employees, speaking about the death of the cardiac patient, said the incident was not reported to the patient safety authority. Another person said that “there were unsafe staffing in the Emergency Department that may have contributed to the death of the patient and this was not reported to the Patient Safety Authority.”

Two hindered thirty three RN shifts were not filled from June 21, 2011 through July 23, 2011. The ED had insufficient staff to cover all shifts.

From May 22 through June 8, 2011, the Emergency Department was used for inpatient care, which is not allowed. The ED was not designed, equipped, and staffed for inpatient care. This is a violation of patient-limit regulations in the Pa. Code. Beds in the ED were used as inpatient beds for up to eighteen hours. CRMC knew that these patients were considered “inpatient” as the billing confirmed it. Two hundred people were held in this manner in violation of regulations. Sadly, this was a repeat deficiency which had been raised in March of 2009.

Joe Chapman
SCHMIDT KRAMER PC
209 State Street
Harrisburg, PA 17101
(717) 232-6300

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