Penn State Hershey Medical Center cited in death of 6-year-old boy

Written by John Latimer/The Lebanon Daily News | Aug 24, 2017 7:11 AM

FILE PHOTO: Courtesy Penn State Hershey Medical Center

(Hershey) -- Penn State Hershey Medical Center has been cited by the Pennsylvania Department of Health for the death of a six-year-old boy and its handling.

The death occurred the day after the boy was brought to the HMC emergency room on Jan. 10 but was not reported to hospital authorities until March 3 after the Pennsylvania Patient Safety Authority received an anonymous letter from an employee.

The hospital then waited until March 29 to contact the state Department of Health, which conducted an investigation on April 12.

The results of that investigation were first reported by medical reporter Walter F. Roche Jr. on his health care blog and Facebook page

According to the Department of Health's Inspection report from the April 12 investigation, the boy arrived at the hospital about 3 p.m. with a temperature of 89.4 F and was placed in a heated blanket called a Blair Hugger.

The boy's temperature was monitored five times between 8 p.m. and midnight as it gradually rose to 98 F, which is near normal body temperature.

The boy remained in the Blair Hugger with it's setting on high throughout the night, according to the DOH report. However, there were no other temperatures documented until 10 a.m. when he a physician discovered the boy had no vital signs and a temperature of 107.6 F.

The boy was taken to the pediatric intensive care unit where efforts to save him were unsuccessful and he was pronounced dead at 5:39 p.m.

When interviewed, the night nurse, claimed that she had taken the temperature but failed to document them, according to the DOH report.

"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," she told DOH investigators.

In addition to its failure to report a serious incident within the required 24 hours, Hershey Medical Center was cited for several other infractions, including failure to meet standards of care, and failure to evaluate and ensure the orientation of agency nurses when hired.

The hospital was ordered to provide immediate corrective actions and did so on April 13, including its procedures for the the use and monitoring of patients with heating and cooling devices, according to the DOH report.

In a statement, Hershey Medical Center expressed sorrow for the death and took responsibility for the errors. However, is also noted that the nurse was from an outside agency, and the boy had "ongoing, complex and life-limiting health issues" when he arrived, including a possible blood infection. 

The hospital also stated that it took corrective action immediately and "(a)s a result of the period of time between the onsite investigation and receipt of the formal written notice of the citations on June 26, the vast majority of the action items have already been completed, and accepted by the DOH."

A portion of the statement reads as follows: 

"As an organization that holds itself accountable for providing the highest quality care while protecting the safety of patients, employees and visitors, we recognize this situation as an unacceptable failure. We expect more of ourselves as a system and as individuals committed to the highest standards of care for each person we serve. We have responded with the utmost of focus and determination to do better. During the DOH on-site investigation, we immediately developed a corrective plan of action for each issue identified. Just as importantly, we launched our own investigation to determine what happened, how it happened and how to prevent it from ever occurring again."

*As a note of disclosure Penn State Hershey Health is a financial supporter of WITF's Transforming Health Project*

This article is part of a content-sharing partnership between WITF and the Lebanon Daily News.

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