Hershey Medical Center cited for care delays that contributed to 2 patient deaths

State health officials recently issued five citations against Penn State Health's Milton S. Hershey (Pa.) Medical Center over delayed care for three patients, two of which later died, according to a report from Lebanon Daily News.

Here are six things to know.

1. The citations and subsequent corrective actions stemmed from an unannounced special monitoring survey conducted by the Pennsylvania Department of Health from July 3 to July 21.

2. The investigative survey found the hospital was noncompliant with several state requirements and regulations. The hospital failed to implement emergency procedures in a timely manner after a pediatric patient was assessed as having an elevated heart rate and high temperature. The child went into septic shock and was moved to the intensive care unit. Several days later, the child met criteria for brain death. The state found the rapid response team should have been called in to care for the patient around noon the day of incident. The team was called at 3:30 p.m. according to the Lebanon Daily News.

3. In a second case, the state found the hospital failed to initiate a "brain attack protocol" in a timely manner on June 11. The protocol is meant to be initiated when a patient has had or is having a stroke. Hospital staff observed the patient was "not making sense, slow to follow commands/had difficulty following commands" at 9:56 p.m. At 12:15 a.m., a nurse documented a discussion of the "need to call emergency department brain attack at this time. Awaiting further orders."

4. On July 22, an injured patient who fell was admitted to the hospital from the emergency department. The staff ordered medication to treat blood clotting issues at 5:47 a.m. It was confirmed by the pharmacy at 6:49 a.m., but not administered to the patient until 8:36 a.m. The patient later died from a subdural hemorrhage. After conducting employee interviews, investigators determined part of the delay was caused by nurses waiting for a shift change before administering the medicine, according to the Lebanon Daily News.

5. The hospital will take several corrective actions in the wake of the citations, including educating staff about the rapid response team process, medication turn-around times and brain attack protocols.

"Instances such as this are inconsistent with the high-quality care our community has come to expect from us — and which we expect from ourselves," said the hospital in a statement obtained by Lebanon Daily News. "We deeply regret when we fall short of those expectations. We realize the importance of our ongoing efforts to evaluate and improve our patient care practices; to ensure staff have the knowledge they need to consistently meet the highest standards of care; and to reinforce expectations for employees to elevate concerns they may have, particularly where patient care is involved."

6. The hospital has come under fire for patient safety issues in recent months. In August, state health officials cited the hospital in the death of a 6-year-old boy who was admitted to the emergency room Jan. 10 with low body temperature. The boy was subsequently wrapped in a heated blanket overnight and found dead the next morning.

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