Hospital Failed to Monitor Patient

By Walter F. Roche Jr.

A patient at a Bucks County hospital who was supposed to be monitored every hour was not checked for seven hours when he was finally found unresponsive.
The November incident at Saint Mary Medical Center prompted inspectors from the state Health Department to declare a state of immediate jeopardy when they arrived at the facility in early December.
The details of the case were spelled out in a report just made public by the state agency.
The report does not indicate whether the patient recovered and hospital officials did not respond to a series of questions.
According to the report the patient, who had a history of diabetes and a heart condition arrived at the hospital on Nov. 23 and a physician ordered that he be placed on a continuous insulin drip. Under hospital policy that meant the patient was supposed to be monitored every hour for glucose levels.
According to the report, hospital records showed that the patient was not monitored at all from 10:45 a.m. till 7:08 p.m. when he was found unresponsive.
"Glucose measurements should have been taken every hour," the report states, adding that "a patient has a right to receive care in a safe setting."
In response to the immediate jeopardy declaration, hospital officials drew up an immediate response including staff education and a system to create an alert whenever a continuous insulin drip is ordered.
The state of immediate jeopardy was lifted at 8:12 p.m. on Dec. 12 after the immediate response plan was approved.
According to the report the employee, identified as Employee 3, who was supposed to have monitored the patient was on leave and unavailable for interview.
"Employee 3 did not follow the appropriate physician's orders," the report states.
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