Hospital Safety Reports: St. Luke’s Failed To Protect Patient From Fall, Lvhn Missed Medication

St. Luke’s Hospital-Anderson Campus didn’t do enough to prevent a patient from falling and injuring their head, a report from the Pennsylvania Department of Health shows.

Two reports from the Pennsylvania Department of Health dated Dec. 16 focus on a patient who fell and injured themselves after bed alarms were turned off. These reports were among several from the state that cited either St. Luke’s University Health Network or Lehigh Valley Health Network, part of Jefferson Health, for not complying with state regulations over the last several months.

The Morning Call periodically checks the state’s hospital health and safety report database for violations documented by the Department of Health at LVHN and St. Luke’s University Health Network-operated hospitals and other major health providers in and around the Lehigh Valley. More often than not these reports state that hospitals are in full compliance or only detail minor violations related to internal records keeping or policy issues.

However, some reports cover instances where patients could have been put in harm’s way or their care was impacted by violations identified by the department.

Patient in ‘immediate jeopardy’

The December state inspection at St. Luke’s-Anderson determined the Bethlehem Township hospital put the patient in “immediate jeopardy,” the most serious determination a hospital can receive, by failing to follow its own policies for protecting patients at a high risk of falling. The hospital could have lost federal funding had it not taken steps to rectify the situation, which it did immediately, records show.

Sam Kennedy, a spokesperson for St. Luke’s, said the inspection results were based in part on information that St. Luke’s self-reported to the state.

“As one of the highest-rated health systems in the country for quality and safety, we appreciate the opportunity to participate in this process designed to promote learning and improvement,” Kennedy said.

The Pennsylvania Department of Health does not comment on health and safety reports.

The report shows a patient at the hospital from at least Nov. 29 to Dec. 7 was determined to be at high risk for a fall. This was consistently reaffirmed throughout the patient’s stay via reassessments. As part of the precautions to keep the patient safe, bed and chair alarms were in place.

However, an employee of the hospital told investigators that while staff members were caring for the patient, the bed alarm was turned off and wasn’t reactivated when they left the room. Some time later when the patient was alone, the patient tried to get out of bed and fell, hitting their head. Staff found the patient on the floor near the door to the room.

A CT scan showed that as a result of the fall, the patient suffered a subdural hemorrhage, bleeding that occurs in the membranes surrounding the brain that can be potentially fatal if left untreated.

In response to the reports, leadership at St. Luke’s-Anderson told the Department of Health that all inpatient nursing staff at the hospital were required to undergo reeducation on the hospital’s fall prevention policies. Staff also was required to document if the bed alarm was on every time they interacted with a patient. The unit charge nurse was required to watch five of these interactions per shift to ensure staff were following the new requirement and counsel them immediately if bed alarms were not used appropriately.

Audits of documentation were also to be performed, and results were to be reported to hospital leadership.

Other events

St. Luke’s-Anderson was not the only St. Luke’s hospital cited in the last several months for not doing enough to prevent patient falls; a similar situation also occurred at St. Luke’s University Hospital-Fountain Hill in August, reports show.

On Aug. 24, a patient was admitted after they had tripped or slipped and fallen. Because of their risk of falling again, fall precautions were put in place, which included bed alarms. However, at 2:11 a.m. on Aug. 26, the bed alarm shut off and remained off hours later when the patient had a fall at 7:56 a.m.

The report does not say whether the patient was injured or not by the fall. However, it does state the hospital didn’t note that the bed alarm was turned off at the time of the fall in patient records, which it was required to do.

In response to the report, St. Luke’s required the nursing staff of all adult inpatient units at Fountain Hill to complete fall prevention education, and clinical staff were reeducated about the hospital’s requirements for documenting unusual incidents in patient medical records. Audits also were completed to ensure bed alarms are activated for high-risk patients and that it is documented. The results of the audits were to be reported to hospital leadership.

St. Luke’s Hospital-Miner’s Campus was subject to two reports, in October and December, that showed on numerous occasions hospital staff did not document patients’ vitals immediately prior to them being discharged or transferred to another facility. Both reports also showed that hospital staff on multiple occasions didn’t document reassessments of patients’ pain and in some cases, providers were not informed that patients were experiencing high levels of pain and no medicine was ordered for the patients.

By not documenting patient vitals or pain scores, St. Luke’s violated its own internal policies and state regulations. Hospital leadership told the Department of Health that emergency department nursing staff and radiology staff would receive mandatory reeducation on the hospital’s guidelines. Guidelines would be modified if necessary and audits of emergency department patient charts were completed to ensure that staff was in full compliance.

Lehigh Valley Hospital-Cedar Crest was cited on Nov. 5 for not sending prescriptions for one psychiatric patient to the pharmacy at the time the patient was discharged.

On Oct. 7 a patient was admitted to the hospital’s Inpatient Behavioral Health Unit for mental health issues. The patient was prescribed an antihistamine for anxiety, a mood stabilizer and an antidepressant. However, when the patient was discharged on Oct. 18, only some of the prescriptions were written and sent to the patient’s pharmacy. This led to the patient having to call the hospital twice to get the prescriptions.

According to the report, hospitals agree to provide each patient with the best quality of care; by not filling this patient’s prescriptions on time, LVH-Cedar Crest failed to do that.

In response to the report, LVHN said leadership had spoken to the provider in charge of that patient’s prescriptions and to all inpatient behavioral staff. Audits were performed on patient discharge charts.

Lehigh Valley Hospital-Pocono was cited on Sept. 30 for not ensuring round-the-clock urology services were available.

On Aug. 31, a patient was admitted to the hospital suffering from an obstructive kidney stone, a urinary tract infection and septic shock, a life-threatening condition where a person suffering from an infection experiences extremely low blood pressure and organ failure due to an extreme immune response. According to the report, the patient’s medical record showed they needed immediate urology services and were transferred to another facility the same day, due to a lack of urology coverage at the hospital.

State investigators found that on Aug. 31, there were not enough urologists on call to cover the entire 24-hour period, which violated state regulations and requirements. In response, LVHN told the state that it would add urology telemedicine services to LVH-Pocono and emergency department staff would be informed of this. The hospital also would audit the charts of patients who present to the ED with urological needs and report findings to hospital leadership.

Jamie Stover, spokesperson for LVHN, said the network is constantly evolving and implementing changes to achieve the highest quality and continuity of care.

“Lehigh Valley Hospital-Pocono is offering 24-7 urology telemedicine services opening access to our specialists across the network,” Stover said. “We are auditing physician discharge plans and re-educating staff follow-up support to ensure patient questions and concerns are addressed in a timely manner.”