PA Hospital Faulted in Drowning

By Walter F. Roche Jr.

Staff at a Pennsylvania psychiatric hospital didn't notice for 20 minutes that a patient had not returned with 11 others from a pond located on the facility grounds.
That was one of the findings of state health inspectors investigating the July 24 drowning of a 46-year-old woman at the Wellspan Philhaven Hospital in Mt. Gretna.
The report made publc this week concludes that the hospital was out of compliance with state and federal licensing requirements because it failed to provide care in a safe setting. The report cites "substantial deficient practices related to the on-site investigation for a patient death."
According to the report the unnamed woman had previously told staffers that she wanted to kill herself.
"I wish I just had a big knife and could just cut myself and be done. I want to be put in a place and let go until I die," the patient was quoted as saying.
A review of records and interviews showed that the victim was one of 12 brought to a pond on the grounds of the hospital, but when the group was brought back to the living quarters just before 5 p.m., no one noticed that only 11 returned.
"The staff failed to notice that the patient did not return to the unit," the report states, noting that hospital protocols required staff to accompany clients on all off-unit activities.
After her absence was noted staff pulled her body from the pond and attempted resuscitation but the effort failed.
The state surveyors also noted that the hospital staff had never addressed the patient's swallowing issues.
She had told a hospital worker, I cannot eat or drink. I am very weak."
Although the hospital did install a temporary fence around the pond and promised to re-educate staff on patient safety checks, an approved plan of correction was not filed.
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