Wednesday, August 8, 2018
State Cites Paoli Hospital in Telemetry Error, Death
By Walter F. Roche Jr.
For the second time in four months state officials have cited a Pennsylvania hospital in a case in which a patient died when a telemetry alarm was mishandled.
In a report on the Paoli Hospital recently made public, state surveyors found that the hospital, part of Main Line Health, "failed to ensure a safe environment for patients on telemetry."
Main Line spokeswoman Bridget G. Therriault said the incident was "the result of employee conduct that violated our established policies, procedures, and practices. The employee involved in the event has been terminated."
The state health surveyor, who visited the 231 bed hospital on a complaint investigation on June 18. declared a state of "immediate jeopardy" after reviewing records relating to the patient who died on May 28.
The hospital responded with an immediate action plan later in the day and the state of immediate jeopardy was lifted. However the facility has yet to file an overall plan of correction satisfying state regulators.
"An approved plan of correction is not on file," the report states.
The records reviewed showed that when a nurse went to check on the patient, whose condition was being monitored electronically, there was no pulse. A code blue was called but the patient had "passed away," the report states.
The records reviewed by the state showed the technician assigned to monitor the patient had repeatedly silenced the alarm after attempts to reach the nurse assigned to the patient failed. Those failed efforts came on phones provided by the facility.
The inspection showed there were repeated failures with the phone system with battery packs falling out. The report states that some employees had resorted to taping the batteries in an attempt to keep them in place. Other used elastics to hold the batteries in position.
The battery pack falls out all the time, one hospital employee told the surveyor.
According to the report not only did calls go unanswered but callers could not even leave a message. And even when calls went through reception was poor.
"Sometimes we cannot make or receive calls," another employee told the surveyor.
The report states that alarms were not to be silenced until the monitor technician "establishes direct verbal contact with the nurse caring for the patient."
Earlier this year the state health agency cited Nazareth Hospital in a similar incident involving a death and the failure of telemetry monitoring.
Therriault said the hospital instituted its own investigation of the incident and reported it to state officials.
"In addition, we reached out to the patient’s family to explain what had transpired and to express our deepest regrets," she said in response to questions.
She said that hospital officials were continuing to work with state officials in developing action plans to address outstanding issues.
"Main Line Health’s first priority is to ensure the safety of all those who rely on us for care," she concluded.