Lancaster General Hospital develops plan to address safety after receiving PA Dept. of Health citation

LANCASTER — Penn Medicine Lancaster General Health is creating a new executive position responsible for overseeing all clinical operations after being cited by the Pennsylvania Department of Health on Feb. 15 for a safety violation.

The violation was in regard to an October 2018 incident in which a patient walked out of Lancaster General Hospital and was found across town, the department report said.

The Dept. of Health report says a national search is being conducted to fill the new position at Penn Medicine Lancaster General Health — Chief Operating and Integration Officer.

LG Health president and CEO Jan Bergen called an emergency meeting of system leaders to address the issues raised by the Department of Health report.

According to the report, a cognitively impaired patient walked out of Lancaster General Hospital on the night of October 12. Staff at the hospital was unaware the patient left, the report said. The patient was located across town at the UPMC Pinnacle hospital, about a mile and a half away from LGH, and was safely returned.

The Department of Health report said the patient had been admitted to LGH after visiting the emergency room on Sept. 20 from the locked dementia unit of another healthcare facility. The patient had refused to take medications and attempted to hurt residents and staff at the other facility, the report said.

During the patient’s stay at LGH, the patient attempted to leave the nursing unit seven times, according to the report.

The report noted that LGH attempted interventions like a sitter and alarms, but the patient turned the alarms off.

LGH does not have a locked unit, according to the report.

The patient encountered security after leaving the nursing unit, and was found standing on the emergency room ramp wearing a pair of staff scrubs in 49-degree weather, the report said. The patient claimed to be an employee when questioned by security.

After making sure no one was missing from the emergency room, the report said, security told the patient to have a good evening.

The Dept. of Health report called for immediate action on Feb. 15. When the hospital submitted a plan about 90 minutes after the report was issued, the plan was accepted by the department, the report says.

Lancaster General spokesperson Jon Lines told LancasterOnline the precautions the hospital developed under the department’s guidance include:

  • special gowns for cognitively impaired patients
  • signs on the nursing unit to help identify patients at risk
  • safety huddles on the nursing units
  • a screening tool on the electronic medical record
  • a daily report for the chief nursing officer that outlines elopement risks

The report listed several correction plan recommendations, including the reduction of time it takes to fill a staff vacancy by recruiting based on anticipated needs, instead of waiting until a vacancy occurs.

Jan Bergen, president and CEO of LG Health, issued the following statement Tuesday:

We take patient safety very seriously and are committed to continuously improving the quality and safety of our care. We deeply regret that our patient care fell short of the standards for excellence our staff fulfill each day. We fully accept the Department of Health’s findings and, with its guidance, developed a corrective action plan that includes educational and procedural policies in our daily operations.

Nothing is more important than our responsibility to ensure safety and quality in every care setting and in every patient interaction. We will continue to work with our governing agencies, including the Department of Health, to demonstrate our commitment to patient safety to ensure implementation of our corrective actions.

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