The Pennsylvania Department of Health has outlined plans of correction for Wellspan York Hospital after a patient died after being left unattended, the report said, for more than an hour on August 16.
The report said after arrival at 9:59, the patient was placed in a wheelchair from the ambulance stretcher and was put in the waiting room by EMS. The timeline of the report shows the patient underwent triage at 10:13 and had a sepsis screening and their vital signs checked.
But, the report adds, "no movement by the patient was noted" from approximately 11:09 am until the patient was approached by staff at 12:20 pm. The report adds, "staff was observed to have walked past the patient approximately 12 times and staff were observed coming out of the Triage Room approximately seven times. It was observed that some of the staff were within 1-2 feet of the patient."
The report laid out the timeline of events like this:
9:59: Patient arrived in ED.
9:59:28 Emergency encounter created.
9:59:38 Arrival Complaint: Nausea.
10:13:15 ED Triage Notes: Pt to ER via ems for n/v, Addendum: dizziness since last night. Hx of vertigo. ... pts temp is low. Having difficulty getting pulse ox.
10:14:53 Onset: Last night. ...
10:15 Sepsis Screening: Does the patient have any of the ?: No signs/symptoms.
10:15 Patient Acuity 3... 10:15:19 Triage completed.
10:20 Patient Acuity: 2.
10:25:07 Vital Signs: Heart Rate 120!, Resp: 28!, BP: 115/89.
12:05:58 ED LWBS (left without being seen). ED Disposition set to LWBS after Triage ...
12:20 Acuity/Destination. Patient Acuity: 1.
12:25 Code Start: code initiated upon pts arrival to room ...
13:31 Deceased Patient's Information: Pronounced by ...
14:29 ED Note Addendum: At approximately 1225 Pt was brought to room 306 after being found unresponsive in ED Lobby. When this RN entered room resuscitation efforts were under way
Read more about the patient's death here and Wellspan York Hospital's statement.
The report listed corrective actions for the hospital to take after the facility was found "not in compliance" with the PA Dept. of Health's rules and regulations for hospitals after an unannounced onsite special monitoring visit was completed on August 22, 23, and 30th, according to the state's Department of Health.
Corrective Actions Include:
- Taking reasonable steps to conform to all applicable Federal, State, and local laws and regulations
- Requiring all Emergency Department staff to undergo retraining
FOX43 asked both the Pennsylvania Department of Health and Wellspan York Hospital where the hospital stood in implementing those actions.
The Department of Health referred FOX43 to this report here.
Meantime, Wellspan issued this statement:
"There are issues related to staffing in the Department of Health report and we are working to address them. The hospital has already implemented a significant number of process improvements and other key changes and actions as highlighted in the report. We continue to redesign our processes to ensure access to high quality, timely care for all." - Ryan Coyle, Wellspan spokesperson