YORK, Pa. — York Hospital has been cited by the Pennsylvania Department of Health in connection to the death of a patient on Oct. 17, 2019, according to findings released by the department.
Hospital staff members "failed to intervene and provide care" as the patient's oxygen levels went down and their heart rate slowed, the investigation determined.
The citations say that there is no evidence that "staff informed nursing staff or medical staff of alarming vital signs" for a span of 23 minutes while the patient was being treated, the findings conclude.
An employee interviewed by investigators said "monitor tech was unable to respond immediately to an alarming telemetry monitor due to lack of availability of a nurse," the report said.
A nurse's aide went to the room, according to the citations, but no one passed any information to care providers, and there were no visible monitors in the room.
The citations also included new policies implemented by York Hospital to correct the issues raised in the citations.
WellSpan spokesperson Ryan Coyle issued the following statement Tuesday:
"Months ago, WellSpan York Hospital reported an event involving a fragile patient who was seriously ill and had complex medical conditions. An internal review found a communication issue regarding vital sign monitoring had occurred while the patient was being treated by a team of physicians and nurses.
"In response to this incident, our teams have implemented enhanced reporting processes and protocols between nurses, technicians and physicians when monitoring patients with serious and complex conditions.
"This incident was unique, and our improvement efforts were specific to addressing those unique findings. These improvements have been fully approved by the Pa. Department of Health."