St. Christopher's Hospital for Children again faulted for care after third surprise inspection

For the third time this year, surprise inspections by state investigators have revealed serious shortcomings in patient care at St. Christopher's Hospital for Children.

After the latest site inspection, in mid-October, investigators said the North Philadelphia hospital did not do enough to determine why four patients who underwent surgery suffered some kind of treatment-related harm during their stay. One of the patients died, though the cause of death was not revealed in the inspection report.

The hospital also failed to adequately train five nurses who treat patients on extracorporeal membrane oxygenation (ECMO), a form of life support, according to the report from the Pennsylvania Department of Health and Human Services.

St. Christopher's is developing a "comprehensive plan of correction," to be submitted by Dec. 21, hospital spokeswoman Kate Donaghy said in an email Thursday morning.

"We take these findings very seriously, and are committed to taking all actions necessary to correct them," Donaghy said.

In a report from earlier this year, state inspectors said the hospital did too little to find out why nine of its patients had died after heart surgery. Those findings resulted from a surprise inspection in March, one month after the Inquirer reported that one in four babies less than a month old died after undergoing complex heart surgery at the hospital. The hospital stopped performing nonemergency heart surgeries in late January, pending an internal review, and has yet to resume them.

In a separate analysis, the newspaper also found that newborn patients spent twice as long recovering in the hospital after heart surgery as  comparable patients at Children's Hospital of Philadelphia.

The other time inspectors made an unannounced visit this year, also in March, they faulted the hospital for administering 10 times the correct dose of chemotherapy to an 11-month-old cancer patient, Isaac Harrison. They said it was a potentially fatal error that went undetected for five days. Isaac survived, but was sent to CHOP for further care.

The 140-year-old St. Christopher's, owned by Tenet Healthcare Corp. of Dallas, serves a predominantly disadvantaged population, with more than 80 percent of its patients eligible for Medicaid.

The latest state report provides scant details about the four surgeries or what went wrong. Three were listed in the minutes from a July meeting of the hospital's department of surgery, and a fourth was discussed at an August meeting, according to the state.

The report did not spell out whether the death was the result of the hospital's error. The unidentified patient was transferred from another facility, received further treatment at St. Christopher's, and died while under the hospital's care.

In each of the four cases, when state officials asked for proof that the hospital had conducted a thorough follow-up review to identify why the adverse events happened, "none was provided," they wrote.

The investigators laid some of the blame on the hospital's governing body that "failed to assume responsibility to provide oversight and accountability" by not ensuring a full review of the adverse events.

That finding suggests the need for continued scrutiny, said physician Albert Wu, a patient safety expert and professor at the Johns Hopkins Bloomberg School of Public Health.

"They include fairly high-level concerns about governance and quality and safety in the hospital," Wu said after seeing the report.

Regarding ECMO, the life-support device, the state found that "the facility failed to follow its own established policy regarding the initial and continuing education" for five nurses who treated patients connected to the machines.

In each of the five cases, the hospital had "no documented evidence" that the nurse had attended 40 hours of lectures required to maintain their skills in caring for patients hooked to the devices. The hospital also had no evidence that the five nurses had taken a written exam to demonstrate proficiency, the state report said.

The hospital was sued by one family whose son died in 2012 after he was placed on ECMO following open-heart surgery. The lawsuit, which court records show was settled recently for $1.25 million, alleged that the device was operated by a nurse who did not have sufficient training.

During union contract negotiations this year, among the issues nurses raised was temporary reassignment to areas of the hospital outside their core specialty.

Elsewhere in the most recent report, the state faulted hospital employees for placing two children in restraints without authorization from a physician. In one of those two cases and in a third case, employees failed to try less restrictive interventions before resorting to restraints, the report stated. The report did not indicate whether the children suffered harm due to the use of restraints.