The Pennsylvania Department of Health issued a citation against Geisinger Holy Spirit Hospital, a 307-bed non-profit Catholic community hospital located in Camp Hill, just outside of Harrisburg. The department indicated its staff had “failed to protect [a] patient’s safety.” Although staff at the hospital are trained in handling mental health crises, they did not handle this type of situation properly and the patient, who remains unnamed, died.
Geisinger Holy Spirit Hospital medical personnel were caring for the patient on September 26th when the individual suddenly attempted to push past on-duty security guards and leave the facility, according to the health department’s incident report. At that point, the patient was restrained and forced back into bed. The guards then attempted to hold the patient down while the nurse and doctor tried to place restraints on the individual. Eventually, the patient went limp, appeared to be foaming at the mouth and the person’s skin turned blue. The patient went completely unresponsive and a code blue was announced as efforts to revive the individual had failed. Medical personnel said the patient died from a “diffuse anoxic brain injury,” an injury usually caused by severe head trauma resulting from a significant event, such as a car accident or fall.
The health department’s report regarding the situation further stated, “Based on review of facility documents, incident reports, medical records, and staff interviews, it was determined that the facility failed to ensure restraints were in accordance with the order of a physician or other licensed independent practitioner for three of 10 medical records reviewed.” And, the hospital was also cited for failing to report the event to the state Patient Safety Authority or to the patient’s family members, despite the fact that the occurrence was initially considered an “immediate jeopardy situation”. The Pennsylvania Patient Safety Authority was established under Pennsylvania Act 13 of 2002, the Medical Care Availability and Reduction of Error Act, as an independent state agency charged with taking steps to reduce and eliminate medical errors in an immediate jeopardy situation. The hospital’s failure to report the incident to the agency was a clear indication that it didn’t believe the actions of its staff were unwarranted or connected with the patient’s demise.
Following the health department’s involvement, the hospital issued a statement saying, “Geisinger Holy Spirit shares the DOH’s commitment to providing a safe environment for our patients, visitors and employees. While we would prefer not to restrain patients, at times such measures are indicated for the safety of all involved. We are saddened whenever a patient passes away, and are confident that the care our team provided was consistent with Geisinger Holy Spirit’s mission of delivering professional and compassionate care to all.”
State officials, in reviewing the summary, approved a plan of correction moving forward which includes educating staff on the use of restraints and creating a “code grey team,” the details of which were not released. The corrective action report specifically indicates the plan put into place “included staff education on restraint application and reportable deaths, creation of a code grey team and documentation form, restraint logs and auditing tool.”