Monday, March 21, 2022

Missing Monitor Proves Deadly

By Walter F. Roche Jr.

The failure to attach a monitor to a critically ill patient ended with the death of the patient at a Philadelphia area hospital, according to a report from the state Health Department.
In a report on a complaint investigation at the Jefferson-Lansdale Hospital, state surveyors said the patient was found unresponsive and lifeless and without the cardiac monitor that had been ordered by a hospital physician hours earlier.
"The patient expired," the report states.
"Attempts at resuscitation were not succesful." In interviews hospital employees acknowledged the monitor was ordered, "It just was not implemented."
Due to the finding the state surveyors on Jan. 26 declared a state of "immediate jeopardy", forcing hospital officials to come up with an immediate written response.
The hospital came up with a plan to immediately notify responsible employees of the requirement to place monitors on patients immediately or within an hour of their arrival. The "immediate jeopardy" declaration was lifted at 7:12 p.m.
Hospital officials, however, did not file an acceptable plan of correction with the state Health Department and did not respond to a reporter's request for comments.
After reviewing hospital records, the inspectors concluded, "It was determined that a registered nurse failed to follow a physician's order to place a telemetry monitor for cardiac monitoring."
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