Tuesday, August 15, 2017
By Walter F. Roche Jr.
A major Philadelphia hospital has been cited by state health regulators for failure to fully investigate the cause of four unexpected patient deaths in 2016, refusing to provide official records and refusing to allow state surveyors to interview key staffers involved in the incidents.
In a report recently posted on its web page, the Pennsylvania Health Department cited the 701 bed Albert Einstein Medical Center for failure to comply with state and federal requirements in serious cases "involving the clinical care of a patient that results in death or compromises patient safety."
The report was the result of a site visit to the Einstein facility described as an unannounced complaint investigation in early May.
Einstein officials filed a plan of correction in which they promised to institute new patient safety protocols and to use those new standards for all serious events beginning on July 1.
The hospital, however, repeated the assertion that some of the records sought by state inspectors at the time of the inspection are "peer review, protected, privileged documents, entitled to protection under federal and state law."
Einstein officials did not respond to a request for comment.
In the first case cited a deceased patient who had been admitted in late July of 2016 was found looking pale and unresponsive on Aug. 7, 2016. Records examined by the surveyors attributed the death to "excessive sedative use leading to hypo-ventilation and brain anoxia."
In a second case an unidentified patient underwent a colonoscopy on Sept. 23, 2016 and returned "with worsening abdominal pain."
The patient had elected to leave after the procedure "against medical advice," the report states.
The patient, who had apparently suffered a colon rupture, did not survive.
In another case a patient reported to the emergency room on June 21, 2016 with "agitation and psychiatric symptoms."
The patient asked for something to eat and was given a sandwich. The nurse returned to find the patient choking. The patient subsequently expired.
State inspectors asked for records showing required reviews were performed following the death. "None were provided," the inspection report states.
Another death occurred following an esophageal intubation in February. When state surveyors asked for documentation and the results of a "root cause analysis," they were told the documents were confidential and "protected."
In addition, the report states, that no completion dates were included for "action items" set to be implemented as a result of the incidents.
Cited in the report was a requirement by licensed health facilities to "track medical errors and adverse patient events, analyze their causes and implement preventive actions and mechanisms."