State health officials cited Penn State Health's Milton S. Hershey (Pa.) Medical Center in the death of a 6-year-old boy who was admitted to the emergency room Jan. 10 with low body temperature, according to the Lebanon Daily News.
Here are seven things to know.
1. While the boy died the day after he was admitted to the ER, hospital authorities weren't informed of the situation until March 3. The Pennsylvania Safety Authority relayed the information to the hospital after it received a report on the death via an anonymous letter written by a hospital employee.
2. After being told of the incident, the hospital waited until March 29 to alert the Pennsylvania Department of Health. The health department subsequently initiated an investigation April 12.
3. According to the health department's investigation, the boy was admitted to the hospital with a temperature of 89.4 degrees. Hospital staff placed the boy in a heated blanket and monitored his temperature as it gradually rose to 98 degrees between 8 p.m. and midnight.
4. The boy remained wrapped in the heated blanket with its setting on high throughout the night. No other temperatures were documented until 10 a.m. when a physician discovered the patient had no vital signs. His temperature was 107.6 degrees. Efforts to save the boy were unsuccessful, and he was pronounced dead at 5:39 p.m.
5. The night nurse claimed to take the boy's temperature, but failed to record them.
"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," the nurse, who was from an outside agency, told DOH investigators, according to Lebanon Daily News.
6. Health officials cited Hershey Medical Center for multiple infractions, including failure to report a serious incident within 24 hours, failure to meet standards of care and failure to ensure the orientation of outside agency nurses.
7. In a statement obtained by Lebanon Daily News, Hershey Medical Center expressed remorse at the death and took accountability for the errors. However, the hospital said the boy had "ongoing, complex and life-limiting health issues" upon admission that may have included a blood infection.
"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," said the hospital, according to the Lebanon Daily News. "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."
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