Care Questioned in Windber Hospital Death

By Walter F. Roche Jr.

State Health inspectors have determined there were multiple violatons of state and federal mandates in the care provided to a patient who died at a tiny rural Pennsylvania hospital in mid-April.
In a 33-page report recently made public, the state health reviewers found the deficiencies went from the bottom to the very top of the 47-bed Chan-Soon Shiong Medical Center in Windber Somerset County.
The reviewers found the vomiting patient died on April 19 because of a lack of equipment - a functioning sunction machine- and lack of qualified personnel - a respiratory therapist clocked out 15 minutes before the patient went into crisis.
The hospital is owned by a non-profit controlled by Patrick Soon Shiong, a California billionaire and medical researcher. He is listed as the head of a web of non-profits including those controling the Somerset County hospital.
The report concludes that the hospital's board failed to annually review the person responsible for managing the hospital, a requirement. In fact the official's performance was never reviewed.
Hospital officials did not respond to questions about the death and the report. Most of the report centers on the care provided to an unnamed patient who had undergone surgery at the facility.
A review of the patient's record showed an unexplained weight gain starting on April 10 and ending on the date of death, April 19. The patient's weight jumped from 171.8 on April 10 to 192.4 on April 12 and 190 pounds on the day of death.
"No action was taken to address the weight gain," the report states. In addition the patient was suffering from growing edema, spreading from his feet to groin.
The surveyors said that when the patient went into crisis on April 19, a Code Blue was called when a call for a more thorough Rapid Response Team was called for under hospital policies.
In its plan of correction the hospital, formerly known as the Windber Medical Center, realligned staff and re-educated the staff on proper procedures.
The surveyors also found the suction machine first used on the patient was not properly functioning and the lid of a cannister was not secure. A second sunctioning machine couldn't be located even on the crash cart.
Employees questioned said they were unaware suctioning equipment was required on crash carts. The hospital's plan of correction promises they will now be installed.
A review of the patient's record showed that on 34 occasions hospital employees failed to administer physician ordered anti-hypertensive medications to the patient.
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