Geisinger Medical Center (“Geisinger”) in Dansville, Pennsylvania reportedly settled in mid-July 2020 the wrongful death claims involving three premature babies, for undisclosed sums. As required by the settlement, Geisinger accepted full responsibility for the deaths and agreed to acknowledged that the process it used to prepare donor breast milk led to deadly Pseudomonas bacteria infections in its neonatal intensive care unit. While Pseudomonas bacteria are common and are often harmless, the bacteria may pose a health risk to fragile patients such as premature babies.
Pseudomonas bacteria were found in a cylinder used to prepare donor breast milk, on a brush used to clean the cylinder, and in breast milk that had been given to an infant who died on September 30, 2019. Eight premature babies at Geisinger (all born at less than 27 weeks) tested positive for the Pseudomonas bacterium between July 1, 2019 and September 29, 2019.
The CEO of Geisinger stated in a written statement, “The loss of a child is tragic, and this settlement can never replace these young children, however we believe we have taken the steps necessary to prevent future infections and spare other families from this loss.”
From the Pennsylvania Department of Health website:
This report is the result of an unannounced, on-site complaint investigation (WIL19C004I) initiated on October 9, 2019, and concluded off -site on October 25, 2019, at Geisinger Medical Center. It was determined that the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.
Immediate Jeopardy was identified on October 18, 2019, at 1445, based on the facility’s failure to ensure a safe environment through failure to properly sanitize equipment used to process donor breast milk (DBM) and infant formula; failure to have a written policy for the sanitization of equipment used to prepare donor breast milk and infant formula; and failure to properly store human breast milk within appropriate temperatures as recommended by the Human Milk Banking Association of North America.
The facility submitted a plan to correct the identified Immediate Jeopardy, which was accepted on October 18, 2019, at approximately 1730. The immediate jeopardy was abated on October 18, 2019, at 1931, based on full implementation of the plan as evidenced by: removal and destruction of current donor breast milk that was not stored at proper temperatures; the development of written policy related to donor breast milk and infant formula preparation and processing, and equipment sanitation; changes to policies related to donor breast milk storage temperature requirements; resetting the donor breast milk refrigerator’s and freezer’s temperature alarms to Human Milk Banking Association standards; staff education records in the changes to policies, and interviews with staff.
Complaint (WIL19C004I) was substantiated. Deficient practices both related to the complaint and unrelated to the complaint were identified and cited with the details noted further in this report.
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