The failure of a Pennsylvania hospital to take basic steps to protect its patients may have cost a dementia patient her life. 89-year-old Rose Lee Diggs was admitted to UPMC Montefiore for multiple deficiencies during the investigation of her death. Although Diggs was transferred from a nursing home that warned the hospital of her propensity to wander, staff at the hospital failed to take any preventative measures to assure Diggs safety in their facility.
Five days after Diggs admission to UPMC she was found dead on the hospital roof in her hospital gown and slippers in 20-degree temperatures. The Pennsylvania Department of Health determined Diggs was able to access the rooftop through a mechanical room with a broken lock. The last recorded sighting of Diggs by hospital staff was more than 13 hours before her body was discovered.
The health department’s investigation into the death determined the hospital acted improperly when it:
- Failed to assess patients safe care needs
- Failed to take any steps to address wandering behavior- despite the nursing home advised them of this tendency
- Failed to maintain a safe hospital environment
Following the health department’s report, the hospital developed a plan of correction to address the deficiencies. Among the new programs initiated: a ‘Condition L’ plan that causes all hospital employees to help in a coordinated search for missing residents, geriatric or psychiatric nurses are to conduct specific assessments of each patients propensity to wander and a policy to inspect doors leading to outside areas.
The family of Diggs is planning to pursue a civil case against the hospital for their negligent care that caused or contributed to her death. This matter highlights the importance of investigations by health departments into situations involving negligent care in hospitals and nursing homes. Frequently, the information obtained by investigators can be helpful in the course of litigation as witness statements and other valuable information is captured shortly after the incident took place.