Multiple Violations at Philly Pediatric Hospital

By Walter F. Roche Jr.

Nine neonatal patients at a major Philadelphia pediatric hospital were given contaminated baby formula, according to a report from the state Health Department.
The formulae, some contaminated with gram positive bacillus was administered to the patients at the 188-bed Saint Christopher's Hospital for Children, but were not immediately reported to the state Health Department and a patient safety authority as required by law.
The baby formula deficiency was one of several violations turned up in a state Health Department inspection to certify the facility for continued eligibility in the federally funded Medicaid program.
An examination of hospital records showed facility officials concluded a single employee was responsible for the contamination. The report does not indicate whether the errors had any adverse impact on the nine patients.
"Do not allow employee to make formula. Put her back with someone for retraining," the hospital memo stated.
In another memo supervisors said the employee would be given a competency test. She will be put in with someone who will monitor, the memo stated.
"We thought these positive culture results were the result of poor technique," state health surveyors were told.
"Employee 42 was told to remediate the formula room technician," the report states. The employee subsequently resigned, the report states.
In addition to the contaminated formula, state surveyors learned that the baby formula was not being sterilized after preparation.
The records showed Saint Christopher "did not have a registered professional nurse or dietitian in charge of the facility's formula formulation," the 17-page report states.
A site inspection of the facility showed there were undated bottles of formula in a refrigerator and a patient in isolation was not being properly monitored.
A room occupied by a Covid-19 patient did not have a system in place to ensure negative pressure to prevent contamination from the room, the report stated.
"The facility failed to ensure a safe and sanitary environment was maintained throughout the operating suite," the report states citing the presence of an uncovered receptacle to empty bedpans and urinals next to a hand washing unit.
The hospital filed an acceptable plan of correction for only one of the citations. Hospital officials did not respond to requests for comment.
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