Penn State Health Milton S. Hershey Medical Center was cited for two incidents this year, including one involving the death of a 6-year-old boy, according to the Pennsylvania Department of Health.
The department’s report on the first incident at the Dauphin County hospital says the boy was admitted to the emergency room on Jan. 10 with a temperature of 89.4 degrees, was put in a warming device called a “Bair Hugger” and died the next day after his temperature reached 107.6 degrees.
Bair Hugger’s manufacturer says a patient’s temperature should be checked every 10 to 20 minutes, but no temperature checks were logged for a 10-hour span, according to the report, although an employee said, “I know I took temps. I was in the room every hour doing eye drops. I must have not documented, I did not have the computer with me. I was probably busy with something else.”
It also says the incident should be have been reported to Pennsylvania Patient Safety Authority within 24 hours, but wasn’t until March 29, after the authority inquired following what it said was an anonymous report by an employee.
Official counts taken at midnight and averaged across a year put Hershey's occupancy rate at 87.5 percent, but during week days it’s often as high as 105 percent or 110 percent.
The department said it visited the hospital on April 12 and 13 in connection to the incident and approved an immediate action plan including “staff education, counseling, policy change, new evaluation process, audits, and competency process change.”
All nursing staff were emailed a reminder of the requirements of reporting patient safety events on April 13, according to the department.
The hospital released a lengthy written statement calling the incident an “unacceptable failure” and saying, “we are deeply saddened that this death occurred and are taking action to prevent this type of event from ever occurring again.”
The statement said the boy had “ongoing, complex and life-limiting health issues” and that an agency nurse had been overseeing his care during those 10 hours.
The statement included a list of changes implemented, including random audits of patient records, restricting pediatric use of Bair Huggers to operating rooms where patients are monitored continuously, and a new process “to more consistently onboard and track all agency nurses.”
The second incident happened April 16, according to the department’s report — just three days after the department’s visit in connection with the first incident.
The report said an infant’s arm was found to be fractured and that the family had asked that a nurse they described as being “rough with patients” not care for the baby anymore.
The incident should have been quickly reported to the Patient Safety Authority and to Children and Youth Services, but was not until April 28, according to the department.
The department outlined a plan of correction including required completion of an educational course by all neonatal intensive care unit employees within 30 days, and a safety alert from the office of the dean & CEO to all hospital employees by Aug. 1 “stressing the importance and requirements of timely event reporting of patient safety events and mandated child abuse reporting.”
The hospital responded to LNP questions on the second incident with a written statement Thursday.
“This was not a case of abuse,” it said, noting that the citation came as “our clinical care and leadership teams were in the midst of an internal review of the case, a review that determined that the injury was not caused by staff nor was it a case of abuse, but likely an accidental injury caused by routine handling of a delicate infant.”
The statement said the circumstances of the injury were also investigated by Dauphin County Children and Youth Services and Derry Township Police.
LNP asked the department whether the hospital faced any repercussions from the incidents other than the requirements outlined in the reports.
Department spokeswoman April Hutcheson responded via email, writing, “There have not been any financial sanctions at this time for these instances. Often, sanctions do not immediately follow the citation as our priority is to make sure the facility corrects the issues and then we can address whether or not additional penalties are warranted.”