MHTC investigation identifies past deficiencies in emergency room care

Staff Writer

Six patients have been identified as receiving less than the standard of care in a recent investigation report released by the Oklahoma State Department of Health on Monday evening. The report follows several months behind an investigation triggered by federal complaints last year, and could cost Memorial Hospital of Texas County its agreement with Medicare if corrections are not made by April 18.

The second page of the report points out five patient cases in which patients had delayed care, lack of care and may have been subject to additional injury or adverse health outcomes. A stroke victim, two teens with suicide by overdose attempts, one rattlesnake bite victim and an infant with repeated history of health complaints brought forth on three separate visits.

In December of last year, problems with the hospital’s contracted emergency room staffing agency, Emergency Staffing Solutions, were brought to the fore. During a report to the trust authority, COO Mike Carter stated he had a “come to Jesus” meeting with ESS in Dallas.

During that meeting, he stated, “Basically I told them, I said look, I’m almost to the point of firing you and bringing in a contractor. The emergency room is the front door of this hospital, and the behaviors and the dissatisfaction that we were receiving by our patients is unacceptable.”

ESS sent a letter to MHTC back in September, threatening to pull coverage in the emergency room unless it received a $25,000 payment. Following a series of reports on closure of the ER, the service remained open and the hospital contracted with a new agency to maintain coverage.

Now the reports on where patients have not received care has been released, raising concerns about where patients might find themselves if they seek out care at Memorial Hospital.

While the report on the hospital survey has just been released to the public this week, staff at Memorial Hospital has been working since the conclusion of the survey in October to make improvements and corrections.

In December, Carter stated the complaints in the emergency room merit focused attention, which department heads and quality control indicated has been taking place in a focused effort. It was indicated that the incidents in the report took place while Memorial Hospital was still in a contract with its former emergency room staffing agency. CEO Doug Swim stated none of the doctors involved in the noted incidents have returned to Guymon.

“Obviously all those physicians have been replaced,” Carter stated. “There were four specific type patient findings in the emergency room… we addressed each of those in the protocols, we’ll have standing orders.”

In the first case listed in the report, it was noted emergency medical services responded to a call in which a stroke victim was transported from their home to Memorial Hospital. It states the patient remained in the ambulance, and was there for 23 minutes before EMS was informed the hospital had no Activase to administer to the patient.

It was noted during an interview on Tuesday that due to changes in law and the current classification of the hospital as a critical care center, hospital staff is not allowed to administer Activase to stroke patients.

“The state law does not allow us to administer Activase to a stroke patient,” Carter said.

Part of that change in law requires the hospital to notify EMS. Stroke patients are flown out of Guymon for care.

“Just to clarify on that, we didn’t lose the ability to do it. The hospital has been classified in a class that can’t give it,” Swim pointed out.

Chief Nursing Officer Kenda Pritchard further elaborated on what the classification and law changes mean.

“We’ve been a Level 4 stroke center for years, and what they have done, is they have actually changed the way the wording of that law reads. Not as a reflection of us, just that they changed the law,” Pritchard said. “We therefore have to comply with what the rule is, which is that we cannot give Activase.”

In the two attempted suicide by overdose cases, concerns were raised when two different individuals were discharged from the hospital without appropriate mental health assessment.

In one case, a 17-year-old girl went to the hospital after ingesting Fluoxetine (Prozac) and Tylenol three hours before going to the emergency room. An assessment at the emergency room identified suicide ideation, suicide attempt, feelings of hopelessness and despair and a depressed mood. It was noted the incident was the teen’s second attempt. Lab tests showed the teen had high levels of acetaminophen in her system and liver function blood tests came in at dangerous numbers above normal.
A transfer request and consent was completed by one ER physician ahead of a shift change. It was noted the income physician did not perform a reassessment of the patient and did not access telemedicine for a mental health assessment by a contracted psychiatrist. The girl was released from the hospital early that morning and recommended to “contact place where you had counseling earlier this year”.

The other suicide attempt was a 14-year-old girl who admitted to ingesting a “handful of Tylenol” 30 minutes before going to the emergency room. Her record indicated family problems and that she was not living with either parent. Labs indicated a critical level of acetaminophen and that the girl tested positive for amphetamines and methamphetamines. No psychiatric evaluation was performed by the ER physician, no suicide assessment was performed, and no mental health evaluation was done via telemedicine. The teen was given contact information for two psychiatric facilities and was discharged to go home with her mother. The ER physician reportedly stated, “The patient was an adolescent and her mother could take her”.

In the case of the rattlesnake bite, a grievance was filed was initiated by personnel in which findings showed the ER physician did not meet the standard of care for the patient. A quality review on the incident said the outcome was “extremely unexpected” practice that “could have (or did) contribute to patient injury”. The record was forwarded for peer review to Emergency Staffing Solutions.

The patient was in the emergency room for less than two hours with no pain assessment and was discharged without further assessment. The next day, the patient was sent to Amarillo by her primary care physician for treatment with anti-venom. The report notes the standard of care states a patient should be monitored for 8 to 12 hours and have repeat lab tests done before discharge, even for those showing no immediate signs of envenomation.

The report notes staff expressed concern that the hospital did not have anti-venom, and would be taking steps to ensure it would be available. Another staffer was reportedly “furious” because the anti-venom and steroids were in fact available, but “they did not do anything for the patient”.

In the case of the infant, the mother visited the emergency room on Jan. 29, 2018, Feb. 5, 2018 and Feb. 8, 2018. The child in each instance displayed health issues with vomiting, constipation, jaundice and some weight loss. The ER physician did no review of the infant’s health history and discharged the child in all three visits.

The child was later transferred from a primary care provider’s clinic to another facility for surgery to correct pyloric stenosis. Pyloric stenosis is a thickening of swelling of the muscle between the stomach and intestines which leads to severe and forceful vomiting in the first few months of life.

There was no evidence the physician ordered any labs or diagnostic imaging. The contracted staffing agency was determined by hospital staff to be the one to address practices dealing with quality. Staff reported the provider had to go through training on pyloric stenosis, but there was no documentation at the hospital to indicate if the training took place. It was also noted that staff was aware the emergency room physicians had problems “dealing with pediatric patients” and the standard of care had not been met.

In all the cases, the survey did not find evidence or documentation of discussions to address or move toward correction of the problems identified. While the survey covered the whole of the hospital, the report only identifies the problems found with the emergency room.

The report states: “Administrator/CEO (Chief Executive Officer, Nursing Executive/CNO (Chief Nursing Officer), Quality Representative and Departmental Directors were ‘responsible and accountable’ for the Quality Management Program.”

Carter noted surveys in both regular rotation and in response to complaints are routine. However, he noted that while they are routine, they should not be downplayed, and this survey is being taken as a serious matter. An exit interview was conducted by the department of health on Oct. 19, and hospital administration went into immediate action well before receiving the report to make corrections and prepare for a plan of correction to submit to the department of health for review.

“At that exit interview, we know we had some issues with the (quality) program, and we had some specific issues identified in the emergency room. From that date onward, we were simply waiting on the survey results… it took a considerable amount of time for that document to be returned to us,” Carter stated.

Memorial Hospital received the 42-page document on Jan. 18, and assembled a multi-disciplinary survey response team to create a plan of correction. Once that was complete, the team reviewed the plan for three days along with inspections of documents, procedures and standing orders, then sent the plan up the chain for further final review before submission to OSDH on Jan. 28, as required.

“It went back to the state department of health. The state department of health will review it,” Carter noted. “If they find the plan of correction acceptable, they will notify us that it is acceptable… if they find it unacceptable, then they send it back to us.”

If the plan of correction is returned, the team will make corrections and amendments as needed and resubmit the plan to the state.

“We are hopeful it will be accepted as submitted on that first write,” Carter said.

Carter went back to Oct. 19, when the surveyors conducted the exit interviews and left Guymon. He noted on the higher levels, there was awareness of the areas in need of review, study, correction and changes.

“We have been making significant changes rewriting policies, protocols, training,” Carter said. “In my career I’ve been to five different hospitals, I’ve been through surveys, complaint surveys. We all go through them.”

He noted that while the survey team was looking over Memorial Hospital, it received another complaint to address with a survey. This created a one week gap in the survey at Memorial Hospital. While hospital administration is taking the survey seriously and making corrections, the hospital was not in “immediate jeopardy”.

“In the hospital business, this is routine. It wasn’t in immediate jeopardy. An immediate jeopardy is the highest level of finding that they can find. (It) means if you don’t cease and desist or correct this situation immediately, we will pull your Medicare certification. It wasn’t anything like that. It was an opportunity for improvement, just like all hospitals have before them,” Carter said.

“We actually have a number of us who have an implementation task team that we are actually working on. We started working on implementation long before they even sent us the (report). We started moving forward full steam ahead immediately,” Pritchard added. “To include a complete overhaul of our quality management system.”

Swim once again reiterated that Memorial Hospital remains open and will stay open into the future.

At the current stage, once the hospital’s plan of correction is accepted by the state, the survey team will return to Memorial Hospital between 30 to 45 days.

Hospital administration and staff state the survey has not been detrimental to Memorial Hospital, but rather, has made the hospital better.

“That’s really the purpose… that’s the purpose of why the state does surveys. That’s why the private organizations like JCAHO… that’s the purpose of that whole process is to bring improvement, not punishment,” Swim said. “The punishment only occurs to those places that don’t respond and don’t follow and don’t improve.”

The plan of correction will become available once it has been accepted by the OSDH, and a report is expected to come after the follow-up survey visit is completed.