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Pennsylvania Hospital Deemed ‘Out of Compliance’ After Dying Patient Goes Unnoticed for 71 Minutes

By Victor Westerkamp

A dying patient was left unattended in a Pennsylvania hospital for over 70 minutes, an inspection report has revealed.

The report from the Pennsylvania Department of Health (pdf) outlines a detailed timeline of the events on Aug. 16. The patient, whose name has not been revealed, was brought in by ambulance with complaints about dizziness and nausea at 9:59 a.m.

After some initial checks, the patient was left alone for nearly two hours from 10:25 to 12:20 when he was found unresponsive.

At 10:15, the man who was seated in a wheelchair was tested negative for sepsis and was assigned acuity level 3. By then the triage was completed, but it was upgraded to level 2, five minutes later.

At 10:25, the patient’s vital signs were taken by an assistant nurse, but the patient never saw a pivot nurse, who is responsible for identifying each patient in relation to the hospital’s tracking board.

Between 10:25 and 12:05, the patient’s name was called three times on the intercom, but the patient did not respond. He was therefore listed as LWBS (left without being seen), and his name was removed from the tracking board.

Surveillance footage shows the patient stopped moving at 11:09 and stayed that way for 71 minutes. Meanwhile, emergency staff passed the patient about 12 times, sometimes as close as one or two feet away.

At 12:20, a nurse addressed the patient and he was found to be unresponsive. The patient was then taken to a private room where a nurse performed CPR, but to no avail. He was pronounced dead at 1:31 p.m.

emergency room
A bright red sign indicating the location of a hospital emergency room in a file photo. (Smith Collection/Gado/Getty Images)

After having made several surprise visits on Aug. 22, 23, and 30, the Pennsylvania Department of Health concluded WellSpan York Hospital was “out of compliance” with requirements laid out in the 1998 Pennsylvania Medical Care Availability and Reduction of Error Act, the York Daily Record reported.

“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.”

“This was a rare event that occurred in our emergency department at WellSpan York Hospital,” Vice President of Medical Affairs Dr. Allan Birenberg said in a statement Friday night. “We take seriously our commitment to provide safe, timely, compassionate care to everyone who walks through our doors. In this instance, we did not meet the high standards to which we hold ourselves every day,” the Daily Record reported.

The hospital failed to report the patient’s death within 24 hours, which is another violation of the regulations, which state a “report will not be delayed for peer review or other quality investigating activities.” WellSpan only did so after a root cause analysis was done.

“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,” the Daily Record reported.

The report concluded the hospital had not provided care that would meet their standards and ordered WellSpan to provide a plan of corrections before Oct. 14 on how the safety issues would be met.