York Patient Dies Despite Monitor Alarm

By Walter F. Roche Jr

An inpatient at a York hospital died without medical intervention even though an alarmed monitor was recording the precipitous decline of vital signs, according to a report issued by the state Health Department.
The facility "failed to intervene and provide care for a patient with declining oxygen and brachycardia leading to death," the report on the WellSpan York Hospital states.
The report dated Dec. 26 came just three days after another Health Department report found that patients arriving at the same hospital's emergency room in October waited well over an hour before having their care transferred from emergency medical responders to hospital staff.
State surveyors said the hospital failed to have adequate licensed registered nurses and other personnel "to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient."
Increased scrutiny of the York hospital follows an August incident in which a patient in the facility's emergency room went unnoticed until he was finally found dead more than three hours after his arrival.
A WellSpan Health spokesman said today that the hospital has implemented enhanced response procedures.
"We have made key staffing and process improvements to ensure the quick, efficient transfer of patients from emergency medical staff to hospital employees," Ryan Coyle wrote in an email response to questions.
According to the Dec. 26 report hospital officials told the state surveyors that the staffer watching the monitors was unable to respond immediately because of a lack of nursing staff.
State surveyors reviewing the hospital's records, found that the initial alarm came at 1:26 p.m.on Oct. 17, when the monitor recorded that the patient's oxygen saturation level had dropped to 77 percent with a pulse of 109 beats per minute.
By 1:45 p.m. the oxygen saturation had dipped to 33 percent and a pulse of 75, the report states.
"The following three minutes show no oxygen reading with a final heart rate of 28 beats per minute," the report continues.
"No evidence exists that staff responded to contact nursing personnel," the report states.
The report notes that corresponding electrocardiogram tracings of the same time period "reveals decreasing cardiac activity until cardiac activity ceased."
"No information was given to care providers about the alarming oxygen saturation or heart rates," the surveyors reported.
The surveyors reported that eventually a nurse's aide went to the patient's room but was apparently unaware of the patient's alarming decline as there were no monitors in the patient's room.
"It was determined that the facility staff failed to utilize good management techniques to avoid the personal discomfort of the patient," the report concludes.
The hospital also was faulted for not including the incident in the patient's personal health record.
In a plan of correction filed with the state York hospital officials said that policies were revised to ensure those monitoring telemetry devices alerted nursing staff to alarming readings. The plan also calls for an auditing system to ensure compliance by staff. The plan also includes education and retraining for staff.
Coyle said the plan of correction was accepted by the state.
The incident is the second in recent months at the 596-bed hospital in which a patient expired without medical intervention.
In an October report, state surveyors found that a patient expired in the hospital's emergency room without even being seen by staffers over a several hour period. Video monitors showed staffers passing within one or two feet of the patient for well over an hour.
State surveyors were told that staff assumed the patient had left when he failed to respond when his name was called. The incident occurred on Aug. 17. The patient was brought to the hospital at 9:59 a.m.. He was finally pronounced dead at 1:31 p.m.
In the state's Dec. 23 review of cases brought by ambulance to York's emergency room in October, four of seven patients reviewed waited for periods ranging from 51 minutes to 73 minutes.
The report refers to a process called "parking" in which emergency room patients are left sitting extended periods while waiting for assessment and needed care.
"The nursing service must have adequate numbers of licensed registered nurses, licensed practical nurses and other personnel to provide nursing care to all patients as needed," the report states.
In a plan of correction filed by Wellspan York, the hospital reported that it had hired two additional nurse recruiters and was offering signing bonuses and providing other incentives to bring on additional staff.