Harrisburg Patient in ER, Dead For an Hour

By Walter F. Roche Jr.

A patient in the Emergency Department at a Harrisburg hospital lay dead in a wheelchair for about an hour before a nurse noticed the patient looked distressed and searched for a pulse. There was none.
Video tapes of the June 26 incident at the UPMC Pinnacle Hospital showed no less than five employees, nurses and a security officer, walked past the woman whose head was hyperextended over the back of the wheelchair.
About an hour earlier the unidentified woman had gone to the registration desk and reported she couldn't breathe.
The videotapes showed she returned to her wheelchair and didn't move again until her lifeless body was found by the nurse at 5:24 a.m. The official time of death was set at 5:46 a.m.
A hospital spokeswoman, Amber Depew, said the faciliity worked with the state to prepare a corrective action plan and that the plan had been implemented and accepted by the state.
According to the report state inspectors, acting on a complaint went to the hospital in late June to examine records and question employees. They declared a state of imediate jeopardy, which forced hospital officials to immediately come up with a corrective action plan.
A plan was submitted about 90 minutes later which called for mandatory reassessment of patients awaiting care in the emergency department including an assessment of whether the patient's condition was worsening.
"The hospital must meet the emergency needs of the patients in accordance woth acceptable standards of practice," the 14-page report states. "The hospital failed to provide emergency care in a timely manner."
According to the report the unidentified woman arrived at the hospital at 3:08 a.m. with chest pains and vomiting.
At 4:07 a.m. she went to the intake desk reporting that she couldn't breathe.
"Patient able to speak in whole sentences," the registration employee wrote in the patient's record.
The next entry at 5:24 a.m.reported the patient's lifeless body had been found and the nurse who discovered it yelling out for help. But that only happened after five other staffers walked past the woman with her head hyperextended over the back of the wheelchair and her left arm outstretched over the armrest of the wheelchair.
The report states that actions or inactions by staff "may have delayed interventions which could have possibly prevented the patient's death."
The hospital's plan of correction includes re-educating all staffers on the need to periodically re-assess patients awaiting care.
"Staff to be vigilant for signs of anything unusual when completing rounds," the plan states. It also calls for periodic audits to assure compliance.
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