In August, WellSpan York Hospital did not report a patient’s death within 24 hours of it happening, which is a violation of Pennsylvania’s Medical Care Availability and Reduction of Error Act.
The patient care inspection report from the Pennsylvania Department of Health says no one helped the patient for more than an hour. The patient was found unresponsive about two hours after arriving in the emergency room and later pronounced dead.
An ambulance brought the patient to the hospital at 9:59 a.m. on August 16, after the patient complained about feeling nauseous and dizzy since the night before (the patient had a history of vertigo). Hospital staff found the patient had a low temperature and they struggled to get a reading of the patient’s pulse oxygen.
Triage was finished by 10:15 a.m. and it was determined the patient had no signs of sepsis. Over the next hour and a half, the patient’s name was called three times and he did not respond. After the third call, hospital staff wrote down “left without being seen” and took his name off the tracking board.
Security camera footage for this time period shows emergency room staff walked past the patient about 12 times.
At 12:25 p.m. the patient was found to be unresponsive. After being moved to a private room, the patient was pronounced dead at 1:31 p.m.
Investigators reviewed security camera footage and found the patient’s oxygen was discontinued after he was transferred from the ambulance into the wheelchair.
The pivot nurse who is responsible for identifying patients and comparing them to the tracking board did not speak with the patient.
According to the Pennsylvania Department of Health report, two other patients who had less-severe ailments were examined and discharged while the patient who died sat in the waiting room.
The Department of Health gave the hospital until Oct. 14 to implement a correction plan to get into compliance with the law. The hospital has taken several steps to try to prevent a similar situation in the future:
- Reassigning nurses to ensure 24/7 coverage in triage and pivot areas
- Reassigning a nurse to assess patients in the lobby whenever someone is in the lobby for more than one hour
- Contracting for 15 travel nurses and filing six positions so far
- Making a new rule that patients are not taken off the tracking board unless there is physical confirmation the patient has left
- Any patients brought via ambulance must be taken to a private bed or triage
The hospital also had emergency department town halls to go over these changes. About 100 staff members were at these meetings and those who could not make it were provided the information in newsletters or smaller group meetings in September.
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