Pennsylvania Department of Health
LANCASTER GENERAL HOSPITAL, THE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LANCASTER GENERAL HOSPITAL, THE
Inspection Results For:

There are 746 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


LANCASTER GENERAL HOSPITAL, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of an unannounced complaint investigation CHL25CS4FH completed on January 12, 2026, at Lancaster General Hospital. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.

Plan of Correction:

103.22 (b)(7) LICENSURE IMPLEMENTATION:

(7) The patient has the right to good quality care and high professional standards that are continually maintained and reviewed.

Observations:

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure established peripheral intravenous therapy policies were maintained prior to a pediatric patient experiencing an infusion extravasation in one out of one MR reviwed (MR1).

Findings include:

On December 24, 2025, review of facility policy "Peripheral Intravenous Therapy" with an effective date of July 29, 2024, revealed "Policy Purpose: To outline the nursing responsibilities in establishing and caring for peripheral venous access devices for therapeutic or diagnostic indications such as but not limited to: 1. Fluids to correct dehydration or acid/base electrolyte imbalances 2. IV medications 3. Blood and blood products 4. Nutritional support and lipids 5. IV contrast dye for diagnostic studies. ... Definitions: Vesicant: An agent capable of causing tissue damage when it escapes from the intended vascular pathway into surrounding tissue. ... Assessment: b. Assessment should minimally include visual assessment, palpation and subjective information from the patient i. Assess IV site more frequently for: 1. Patients receiving intermittent infusions of vesicants a. The nurse should advocate for central vascular access administration of vesicant medications whenever possible. The peripheral infusion of vesicant agents should be limited to less than 24 to 48 hours. ... Types of Peripheral Catheters ... Limitations Not Ideal for Vesicant infusions and site must be assessed every 5-10 minutes for extravasation and prevention ... Assessment Guidelines ... At least every hour Neonatal Patients Pediatric patients ... The peripheral infusion of vesicant agents should be limited to less han 30 to 60 minutes. In addition to visual assessment of the site, patency should be verified every 5-10 minutes for infusions 30 minutes or less."

On December 24, 2025, review of facility policy "Intravenous Infiltration & Extravasation" wiht an effective date of February 22, 2023, revealed "POLICY PURPOSE: To ensure the safe administration and management of intravenous non-chemotherapy and/or chemotherapy irritants and vesicants to patients at Lancaster General Health (LGH) facilities. POLICY STATEMENT: It is the policy of LGH to follow safe medication management practices in order to protect the health and safety of our patients. ... Definitions: Extravasation: Unintentional instillation or leakage of a vesicant out of a blood vessel into surrounding tissue. This may result in varying degrees of impairment including pain, necrosis, and tissue sloughing. ... Any extravasation of medications can result in significant soft tissue and vascular injury. ... Adherence to Infusion Nurse Society standards for assessment of peripheral or central IV administration of medications is recommended to minimize the extent of potential damage. Assessment guidelines are included in the nursing policies Peripheral IV Therapy and Central Venous Therapy. At least every one (1) hour Neonatal patients, Pediatric patients; More frequently: Every 5-10 minutes -Pts receiving intermittent infusions of vesicants. The nurse should advocate for central vascular access administration of vesicant medications whenever possible. The peripheral infusion of vesicant agents should be limited to less than 30-60 minutes. In addition to visual assessment of the site, patency should be verified every 5-10 minutes."

Review of MR1 on January 7, 2025, revealed patient was admitted to the hospital on July 6, 2025, at 7:31 pm with a primary diagnosis of Hypoglycemia and discharged on July 9, 2025, at 4:00pm. On July 6, 2025, at 8:19 pm a peripheral intravenous (IV) line was placed into patient's anterior right foot. Review of medication administration record revealed patient was ordered D10 PEDS bolus - vesicant 4.64ml on July 6, 2025 at 8:45pm to be infused over two minutes; D10 PEDS bolus - vesicant 5 ml on July 7, 2025 at 4:23 am to be infused over two minutes; D10 infusion- vesicant 14 ml/hr continuous July 6, 2025, at 10:30 pm - July 7, 2025, at 6:54 am; dextrose 31.25 g infusion- vesicant 6ml/hr continuous July 7, 2025, at 5:45 am - July 8, 2025, at 3:42 pm; dextrose 31.25g infusion- vesicant 7ml continuous July 8, 2025, at 10:52 pm - July 9, 2025, at 7:15 am.

Between the dates of July 8, 2025, 7:00 am- July 9, 2025 7:15 am IV assessments completed on the right foot peripheral IV are noted July 8, 2025, at 7:38 am; 10:01 am; 1:20 pm; 4:03 pm. On July 9, 2025, at 12:48 am; 2:30 am; 3:31 am; 5:47 am and 7:15 am. On July 9, 2025, at 8:40 am EMP 2 noted infiltration/extravasation at 7:15 am, "Volume of fluid that escaped into tissue: unknown D 12.5 % @ 7 ml/hour. Patient complaints or experience during the extravasation: pain (crying when touched), swollen toes to upper thigh." Note entered by EMP3 on July 9, 2025, at 6:33 pm revealed "On 07/09/25 d12.5 extravasated on RIGHT foot leading to edema and sloughing of skin."

The right foot peripheral IV is noted to be used for infusion of vesicants for longer than 24 to 48 hours. Request was made for documentation defining the need for use of peripheral IV outside of policy parameters requested. None provided.

Review of IV assessments revealed documentation was not completed hourly per policy.

Interview with EMP1 on January 7, 2026, EMP1 confirmed the information documented above is complete and accurate.

Plan of Correction - To be completed: 03/13/2026

Action: Executive responsible for oversight of Plan of Correction

Responsible Party: Chief Nursing Officer

Completion Date: January 14, 2026

Action: Educate staff to requirement for hourly IV checks and documentation required when there is a continuous infusion

Responsible Party: 4 Fred Nurse Manager

Completion Date: January 30, 2026

Action: Revise Peripheral Intravenous Therapy policy with regard to pediatric and neonatal vesicant management and educate 4 Fred Registered Nurses and Pediatric Hospitalists and Neonatal ICU Registered Nurses and Providers

Responsible Party: Vascular Access Team Manager

Completion Date: February 27, 2026

Action: Conduct 5 medical record audits of documentation of hourly IV checks on pediatric patients with continuous IV infusions per week with a goal of 100% compliance. Incidents of non-compliance will result in re-education to staff.

Responsible Party: 4 Fred Nurse Manager

Completion Date: March 13, 2026

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement