By Shelly Stallsmith, York Daily Record, Oct. 15, 2019.
WellSpan York Hospital emergency staff were seen on video walking past a patient in a wheelchair approximately 12 times on Aug. 16.
No one approached the man for more than 70 minutes. Roughly 3 ½ hours after arriving at the hospital by ambulance, the man was dead, according a patient care inspection report by the Pennsylvania Department of Health.
Determined to be out of compliance
WellSpan York Hospital was determined to be out of compliance of Pennsylvania’s Medical Care Availability and Reduction of Error Act after a special monitoring visit was made Aug. 22, 23 and 30.
By law, the hospital was supposed to report the death within 24 hours. An interview confirmed that the report was not entered until after the facility conducted a “Root Cause Analysis,” which is in violation of the law that states the “report will not be delayed for peer review or other quality investigating activities.”
A tragic timeline
According to the timeline in the report, the man arrived by ambulance to the hospital at 9:59 a.m. Aug. 16, complaining of nausea. The triage notes said the patient had complained of dizziness since the night before and had a history of vertigo. The patient’s temperature was low, and staff was having difficulty getting a pulse oxygen reading.
At 10:15, staff determined he had no signs/symptoms of sepsis and an acuity level of 3 was given. Triage was completed.
Five minutes later, the acuity level was upgraded to 2.
At 10:25, the patient’s vital signs were heart rate, 120; respiration, 28; and blood pressure, 115/89.
Between 10:25 a.m. and 12:05 p.m., the man’s name was called three times, and the patient failed to respond each time. After the third time, he was marked LWBS (left without being seen), and his name was removed from a tracking board.
At approximately 12:25 p.m., the patient was found to be unresponsive, according to the report, and moved to a private treatment room. He was pronounced dead at 1:31 p.m.
Investigators also turned to security camera footage, which showed that the patient had his oxygen discontinued when he was transferred from the ambulance stretcher to the wheelchair.
Footage shows vital statistics being taken by a nursing assistant, but that the pivot nurse (responsible for identifying each patient and comparing to tracking board) never spoke with the patient.
“At no time was any staff observed to complete Rounding on [the patient] as per their Rounding policy,” the report states. “No movement by the patient was noted from approximately 11:09 a.m. until approached by staff at 12:20 p.m.”
The report shows that two other patients, with less-severe ailments, were triaged, examined and discharged while the man in question was still in the waiting room.
“We have reviewed what happened and taken immediate steps to correct any issues which contributed to this event,” Birenberg said. “We are committed to doing our very best, every day, for every patient, and we will continue to work hard to make sure that happens.
“To that end, we continue to redesign our processes to ensure access to high-quality, timely care for all.”
Steps to be taken
WellSpan York Hospital had until Oct. 14 to implement its plan of correction:
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- Nurses have been reassigned in the department to make sure there is 24/7 coverage in pivot and triage areas.
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- A nurse has been assigned to reassess patients in the lobby area, whenever the length of stay in the lobby exceeds one hour.
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- The hospital contracted for 15 traveling nurses. Six positions have been filled and the hospital is recruiting to fill the remaining spots.
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- No patient will be taken off of the tracking board without physical confirmation of their departure.
- All patients arriving by ambulance will be taken directly to a private bed or to triage. Anyone with an acuity of 2 or greater will be given a bed.
York Hospital held emergency department town halls twice in September to reinforce the changes and give staff the chance to discuss them. Nearly 100 staff members attended the meetings. Those who couldn’t, were given the information in smaller groups or in newsletters throughout the month.