LANCASTER, Pa. — The Pennsylvania Department of Health (DOH) recently faulted Lancaster General Hospital for mistakes that included operating on a patient's wrong leg and employee violations of hand hygiene rules designed to protect patients from infections.
The infractions were discovered during a series of "special monitoring" investigations by the Department of Health, which a spokesperson said happen when the department has reason to believe there are ongoing problems, and the information came anonymously or from an unusual source.
The most-recent infractions came within two months of the hospital being cited for failing to refill the insulin pump of a patient with diabetes, and failing to file reports related to a new mother who died of internal bleeding, as required by the state, the department said.
According to the DOH, the reported surgery on the wrong leg occurred in December 2022, and involved a patient who needed the operation to reconstruct a ligament and repair an injured left ankle.
The department report said a surgical staff member marked the correct limb, but marked it above the surgical site to avoid having the marking washed away during prep for surgery.
Hospital policy calls for the mark to be made within two inches of the surgical site, the report said.
Another staffer put a tourniquet on the wrong leg, according to the report.
The staff apparently realized the medical error shortly after operating on the wrong ankle, the report said.
According to LGH policies designed to prevent wrong-site surgeries, the surgeon is required to verify the patient's identity by full name and date of birth and confirm the correct surgical site. The surgeon is also required to mark and initial the surgical site, making sure the marks remain visible after the site has been draped and prepped for surgery.
The DOH said it reviewed medical records and discovered two records that contained no documentation of the surgeon identifying the patient after they were placed on the operating table.
The DOH report, which was released on Dec. 16, 2022, also said earlier in the month a department surveyor saw three operating room staff members fail to follow required hand hygiene rules.
The report required LGH to take the following steps in response to the violations:
- Educate staff about procedures aimed at preventing wrong-site surgeries
- Initiate audits to ensure the steps are followed and documented
- Educate staff about the importance of hand hygiene and make sure the policy is followed
In a statement sent to FOX43 on Tuesday, LGH said:
“Ensuring the safety of all patients is our top priority. We take any regulatory or inspection findings very seriously and are cooperating fully with the PA Department of Health on these matters.”
The DOH sent the following statement to FOX43 on Tuesday, explaining why it conducted the on-site investigation at Lancaster General Health:
"The Department of Health (DOH) regulates hospitals to ensure facilities are adhering to state regulations in order to provide high quality care to patients across Pennsylvania. The Department takes complaints seriously and investigates any and all complaints as they are reported through a survey investigation in order to protect patients and families, hold hospitals accountable and help to prevent any potential occurrences in the future.
In reference to this case, a special monitoring investigation was conducted by the Department. This type of survey is prompted if the department has a reason to believe a facility may be engaged in a deficient practice but the information that lead to that conclusion was submitted anonymously or outside of the traditional complaint process. In addition to anonymous submissions, examples would include referrals from other government agencies, self-reporting by the facility, or reporting by another health care facility.
The Department publishes survey findings online in order to help inform the public. While special monitoring surveys are distinguished from complaint surveys in the statement of deficiencies on DOH’s website, both processes are considered confidential, so we cannot disclose what led to a particular special monitoring investigation."