2nd UPMC Hospital Cited in Death

By Walter F. Roche Jr.

For the second time in a matter of days a western Pennsylvania hospital has been cited for failing to monitor a cardiac patient who was later found dead and unresponsive.
In a report made public this week state health surveyors found that a patient at UPMC McKeesport who was supposed to be on a cardiac monitor, was found "slumped over and pulseless" on June 1. Records showed the monitor had become disconnected some three hours earlier but no one responded.
"Time of death was 2:10 p.m.," the report states
That was just days after a similar incident at UPMC Presbyterian Shadyside in which a cardiac monitor became disconnected but no action was taken. That patient was also found dead several hours after the monitor went dark.
In the McKeeport case the health department report states that the patient was admitted on May 31 with a complaint of back pain. A physician ordered a cardiac monitor for May 31 and June 1.
Hospital records show the unnamed patient was discovered with no heartbeat at 1:58 p.m. on June 1. Resuscitation efforts failed and death was declared 12 minutes later.
The hospital also was cited for failing to conduct required cardiac rhythm assessments for the patient and three other cardiac patients in the same time period.
The hospital was also cited for failing to notify state health officials of a serious event within 24 hours of its discovery.
The report dated July 22 was the result of two visits to the facility and was described as an "unannounced special monitoring survey."
The hospital filed a plan of correction in response to the inspection in which it promised a re-education program for staffers on the requirements for cardiac monitoring and assessments for cardiac rhythms.
The Mckeesport report parallels the 18-page report issued on the May 25 UPMC Shadyside incident in which a patient was found unresponsive several hours after the cardiac monitor had became disconnected.
Records showed the monitor lead became disconnected at 11:32 a.m. but no action was taken. The patient was discovered pulseless at 3:52 p.m.
In that case the hospital was also cited for failing to notify the victim's family of the adverse event within seven days.
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