Pennsylvania hospital cited for failing to stabilize patient who died at separate facility

CMS cited Bern Township, Pa.-based Penn State Health St. Joseph after a report from the Pennsylvania Health Department faulted physicians for failing to stabilize a car crash victim before transferring the patient to a different hospital, where he later died, the Reading Eagle reports.

The hospital submitted a plan of correction June 28 to address these citations.

Five things to know:

1. The 59-year-old patient was placed on oxygen upon arriving at Penn State Health St. Joseph, an acute care hospital. The Reading Eagle report did not specify the day the patient received treatment. He had an IV tube inserted and underwent several CT scans. When staff returned to the emergency department, they found the patient's blood pressure had dropped significantly. Hospital physicians provided fluid and blood units to return the patient's blood pressure to normal and told him about treatment options.

2. The patient declined to go to another area hospital, but agreed to be sent to Penn State Hershey (Pa.) Medical Center for surgery, according to the health department report. Before the transfer, a provider at the Hershey hospital told St. Joseph providers that the patient should be transferred only after his condition came under control.

Otherwise, surgery would have been the best option in St. Joseph's operating room before transferring the patient to Hershey for intensive care.

3. St. Joseph had a surgeon on call, but he did not evaluate the patient in person. When the patient was transferred to Penn State Hershey, physicians attempted to control the patient's bleeding, but the patient died that same day. 

4. After the patient's death, Penn State Health St. Joseph failed to report the case to the Health Department or the Patient Safety Authority within 24 hours, as required by state law. Additionally, the hospital did not notify the patient's family within seven days.

5. A spokesperson for Penn State Health St. Joseph acknowledged the hospital had been cited by CMS and the Health Department, according to a statement obtained by the Reading Eagle.

The hospital immediately began to implement measures to address these citations, as noted in a plan of correction the hospital submitted on June 28," the statement said. "We expect the plan of correction to be posted publicly upon acceptance."

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