Unmonitored UPMC Patient Found Dead

By Walter F. Roche Jr.

A patient who was supposed to have been immediately placed on monitors was found pulseless at UPMC Lock Haven on Aug. 12, just after midnight, according to a critical 36-page report from the Pennsylvania Health Department.
According to the report, which was recently made public, the unnamed patient was admitted to the facility on Aug. 11. A physician ordered a continuous cardiac monitor with telemetry. The monitor, hospital records show, had yet to be hooked up when the patient was found lifeless early in the day on Aug. 12.
An order for a pulse oximetry monitor was also ignored.
Hospital officals did not respond to questions on the report.
As the report states, the exact time of death could not be determined, nor could it be determined if the patient could have been saved.
"Therefore," the report states, "staff was unaware the patient was decomposing, resulting in a delay in staff intervention which potentially contributed to the demise of the patient."
According to the report the last check on the patient came at 11:04 p.m., a little over an hour before the patient was found lifeless.
Although an emergency reponse team was summoned, no action was taken because the patient was under a do not resuscitate order.
Citing the seriousness of the deficiency, state health surveyors declared a state of immediate jeopardy, forcing hospital officials to come up with an immediate corrective action plan.
A plan was submitted calling for staff to immediately place cardiac monitors on arriving patients when ordered by the admitting physician.
The report cites the facility for other deficiencies including failure to respond to a patient grievance and failure to adequately supervise the medical/surgical staff.
The surveyors found that other patients were not immediately placed on monitors and still others were not administered pain medications as a doctor had ordered.
Doctors orders were not promptly implemented for four of six cases reviewed, according to the report. In one case a doctor's orders were not implemented for eight hours.
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