Facility Failed to Investigate, Report Patient Death

By Walter F. Roche Jr.

"It was something that just happen."
That's what an employee of the Bryn Mawr Rehabilitation Hospital told a state surveyor when questioned recently about the July 16, 2017 death of a patient.
Following the inspection the 148-bed hospital, part of Main Line Health, was cited for failure to investigate and report the death of a patient who was found unresponsive with her tracheotomy tube disconnected.
According to the report the patient who had been admitted to the Malvern facility on May 3, 2017, was discovered two weeks after admittance with a dislodged tracheotomy tube. The patient was unresponsive without a pulse and resuscitation efforts were unsuccessful.
As the May 8 report states, the state Medical Care Availability Act required that the hospital report the event within 24 hours of its discovery. Reports must be filed both with the state Health Department and the state Patient Safety Authority.
Events that must be reported, the state surveyors noted, are unplanned occurrences not consistent with the routine care of the patient.
When asked why the hospital did not report the death or do its own investigation of the incident, a hospital employee said, "It was not perceived as a reportable event. It was something that just happen during the course of the patient's hospitalization."
The hospital also was cited for failing to comply with hand hygiene standards even though its own records showed compliance in some areas of the hospital only achieved a 40 per cent compliance rate.
Neither the July 17 death nor the hand hygiene issues were reported to the hospital's quality control committee.
Still another citation was issued after inspectors discovered the hospital had upgraded its nurse call system without the state being notified 60 days in advance. The inspectors also found fault with credentialing actions at the facility.
State Health Department records state that the facility has yet to file an acceptable plan of correction, but a hospital spokeswoman issued a statement expressing confidence that the latest submission will be accepted.
"Bryn Mawr Rehabilitation Hospital’s first priority is to ensure the safety of all those who rely on us for care. We have submitted a plan of correction and are confident that our plan addresses and corrects the issues identified, and demonstrates Bryn Mawr Rehabilitation Hospital’s and Main Line Health’s ongoing commitment to a culture of safety and highly reliable, quality care," said Mary Kate Coghlan.
The facility did not respond to specific questions about the patient cited in the report.
Contact: wfrochejr999@gmail.com