Friday, June 29, 2018

Reading Hospital Faulted in Patient Death

By Walter F. Roche Jr.

A Reading hospital has been cited for violations of state and federal law in the treatment of a 59-year-old woman who was critically injured in a two-car April accident and died later the same day.
In a 10-page report the Pennsylvania Health Department found that Saint Joseph Medical Center, part of Penn State Health, failed to stabilize the woman before having her airlifted to the Penn State Milton S. Hershey Medical Center.
The state surveyors found that the handling of Debra A. Becker's case violated the federal Emergency Medical Treatment and Labor Act (EMTALA), better known as the Anti-Dumping law.
In addition the report states that the hospital failed to comply with a state law requiring the reporting of serious or sentinel events to the department and a related state authority.
In a statement issued today officials of Penn State Health acknowledged that the Reading facility had been cited by state and federal officials.
"The hospital immediately began to implement measures to address these citations, as noted in a plan of correction the hospital submitted June 28. The plan is due July 2. We expect the plan to be posted publicly upon acceptance." the statement read.
According to the report, which does not name the victim, she was brought to the St. Joseph's emergency department at 9:54 a.m.following an accident in which her car was T-Boned.
The patient's daughter, Karin Vasquez of Lancaster, said the patient was her mother who died on April 28, the same day as the accident. Her mother died after being transferred to the Hershey Medical Center, also part of Penn State Health.
Vasquez said she was rebuffed in her attempts to get information from the Reading hospital.
"I didn't get any information,"she said.
All she was told, Vasquez said, was,"We did everything we could."
The state report however, found fault with what the hospital did while Becker was at the facility and even after she was airlifted by helicopter to Hershey.
Though an IV was inserted immediately after she arrived at the hospital shortly before 10 a.m., no fluid was started until an hour later. After a CAT scan and other tests were completed, the report states, her blood pressure had plummeted to 64/44.
Finally at 11:07 a.m. two liters of saline solution were started.
Meanwhile tests showed multiple rib fractures and likely complex lacerations of the spleen, according to the state report.
A half hour later, the report continues, the patient complained of difficulty breathing. She was also reported to be sweating profusely.
"Decision made for transfer to trauma facility," the report states citing hospital records.
Citing those hospital's record, the report states,"it was determined the facility failed to provide an appropriate transfer within the capability of the hospital."
A Hershey Medical Center staffer told state surveyors that they told their colleagues at St. Joseph that if the patient was unstable she "needs to go to the OR (operating room) and then be transferred."
However, the report states,"The patient did not go to the operating room" and "the surgeon (at St. Joseph) did not evaluate the patient."
At Hershey surgeons attempted to stop the bleeding but the patient's heart stopped and she could not be revived. Death was declared at 1:46 p.m., according to the report.
The state surveyors concluded that the hospital also failed to comply with the state Medical Care Availability and Reduction of Error Act (MCARE) by not notifying the Health Department and the Patient Safety Authority within 24 hours of the incident.
The report also faults the hospital for failure to notify the patient's family of a "serious event" within seven days.
Vasquez said the family has yet to receive any notification from the hospital. Nor were they informed of the state Health Department findings.
"I am more than sure this was my mother. I wish it wasn't," Vasquez said after reading a copy of the report provided by a reporter.

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