Write-ups by state demand hospitals respond to correct problems, learn from 'near misses'

10/21/2012

The Blade/Dave Zapotosky
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One night last spring, a Mercy St. Vincent Medical Center patient was one of 17 at the hospital on suicide watch — people who are supposed to be checked by a nurse every 15 minutes.

This particular paranoid schizophrenic patient, who was admitted against his will, fell through the cracks. The mentally ill patient took his life and the hospital was written up by the state as a result. That write-up was one of several levied by the Ohio Department of Health against Toledo-area hospitals over the past decade, a Blade review of public records found.

Hospitals operated by Mercy and ProMedica Health System — the two big competing health systems in the Toledo area — and the University of Toledo Medical Center have all been paid visits by the state health department. Each time a problem was discovered, or a tragedy such as the suicide at Mercy St. Vincent occurred, the offender had to draw up an “action plan” to fix the problem and try to keep it from happening again.

Officials at all three hospital systems stressed their culture of safety, emphasis on patient safety, and learning from so-called “near misses.”

The Blade reviewed the state health department records of all Toledo-area hospitals after it first looked at University of Toledo Medical Center violations following an incident in August when a viable kidney was discarded before it could be transplanted.

“Nobody is perfect and these things do happen,” said Dr. Imran Andrabi, Mercy’s senior vice president and chief physician executive officer. “Tihese near-misses have to be learning experiences.”

While ProMedica Toledo Hospital has only one negative report with the state health department during the past decade, officials said its managers don’t always report incidents to the Centers for Medicare & Medicaid Services, which could trigger a state health department visit. The reporting is voluntary.

Linda Yielding, ProMedica’s corporate director of quality, said the company’s hospitals have stringent internal reviews that go along with things such as error prevention training and a “good catch program” that rewards people who report incidents that help prevent mistakes.

Mercy and UTMC, the former Medical College of Ohio Hospital, have more state reports showing incidents where they didn’t meet established standards.

The most recent report against Mercy St. Vincent on April 8, 2011, said the suicidal patient could not be located and was eventually found at 10:24 p.m., unresponsive inside the bathroom of an unoccupied room.

“The nurse’s note stated only that the patient was found lying on the floor, unresponsive with no pulse, and a patient gown was around his/her neck,” the state health department record showed. The patient was pronounced dead the next day.

An investigation later showed that a nurse had not actually seen the patient for a 10 p.m. check. Video surveillance showed that the patient had entered a room at 9:49 p.m., minutes after a nurse was supposed to have checked on the patient in bed.

“The video surveillance system is an extra tool available to the staff while at the nurses station, but no one is assigned to watch the monitors as direct observation is what is required,” the state record said.

Dr. Andrabi said the nurse assumed the patient was in the bathroom. The death prompted changes that include new bathroom doors with slanted tops that open in both directions and making sure there are no places a patient could tie a knot.

“Every time something like this has happened, it has prompted us to go in and say, ‘What can we do differently?’ ” he said. “Sometimes you feel like, and I don’t mean this in a wrong way ... the only way to take care of this is if there was absolutely nothing on the patient and nothing in the room, which is not possible and it’s not dignified, and it’s not the right thing to do.”

Mercy St. Vincent was previously cited by the state health department for a patient suicide.

“On the morning of Aug. 21, 2008, [a patient] sustained injuries and subsequent death after jumping through a plate glass window on the hospital’s fifth-floor neuroscience step-down unit,” an Aug. 27, 2008, report stated. “Although hospital staff were aware that the patient voiced a plan to commit suicide by jumping through a window, the hospital failed to develop and implement an individualized plan for the provision of a safe environment to prevent [the patient] from carrying out her suicide plan. ... The medical record lacked evidence interventions were put in place to prevent the patient from implementing her suicide plan.”

The report also said the hospital at that time lacked individualized interventions to prevent suicide for three other patients.

Accredited facilities

While the Ohio Health Department has issued multiple citations against Toledo-area hospitals the past decade, those facilities are accredited by the Joint Commission, a national nonprofit agency.

The Joint Commission is an independent organization that accredits and certifies more than 19,000 health-care organizations and programs in the United States.

Both UTMC and Mercy, which in the Toledo area operates Mercy St. Vincent Medical Center, Mercy Children’s Hospital, Mercy St. Charles Hospital, and Mercy St. Anne Hospital, refused to release copies of their Joint Commission reports.

ProMedica Health System — which in the immediate Toledo area operates Bay Park Hospital, Flower Hospital, St. Luke’s Hospital, Toledo Children’s Hospital, and Toledo Hospital — released to The Blade copies of its most recent Joint Commission reports for those facilities.

The reports — which were from 2012 for Toledo Hospital; 2011 for Bay Park, and 2009 for Flower — said the hospitals’ performances were “similar to the target range [or] value." The ProMedica hospitals did not get an overall “above the target range,” or the “achieved the best possible results” designation from the Joint Commission.

Roy Croy, chief of the Ohio Health Department’s bureau of community health care facilities and services, said the state has no authority to just go in and inspect a hospital without the permission of the Centers for Medicare & Medicaid Services.

Ohio is the only state in the country that does not license hospitals, but the state health department does register hospitals, which are required to complete an Annual Hospital Registration and Planning Report each year. While hospitals are not licensed in Ohio, the maternity unit within a hospital is licensed by the state.

Infection violations

Mr. Croy said one of the most prevalent problems the state health department finds are infection control violations.

“Right at the top is the basic compliance with the simplest of standards and that is hand washing, changing gloves when they should be changed,” he said. “Nationally, health-care acquired infection is a serious issue, and so, yes, you find it everywhere.”

Mercy St. Vincent was cited in an Aug. 25, 2011, report for problems with maintaining a sanitary environment to avoid sources and transmission of infections and communicable diseases, along with problems with its “physical environment,” and failing to meet the needs of patient personal privacy.

“During an emergency room tour on Aug. 22, 2011, surveyors saw a nurse wearing gloves talking to a doctor. The gloves were covered with a bloody substance,” the report said. “The nurse touched the doorknob and door frame with the bloody gloved hands. Three minutes later the same nurse with soiled gloves on, carried a two-gallon plastic container covered with a bloody substance out of room 14 and placed the soiled container on the shelf under the cart/stretcher in the hallway. Again, the nurse left the room and returned to the room with soiled gloves on.”

The lengthy Aug. 25, 2011, report also said a housekeeping staff member who arrived to clean a room was seen soiling her clothes with blood while reaching to clean an exam table.

“The exam table contained two blood-soaked chux/pads. There were four blood-soaked pads on the floor, two blood-soaked pads on the step of the exam table. Also blood was dripping down the sides of the exam table and a large amount of blood [was] on the floor,” the report said. A staff member was seen wiping up blood on the floor with wipes.

“The surveyor questioned the staff regarding the use of the blood spill kit,” the report said. “Staff P looked puzzled and staff Q (housekeeping supervisor) stated: ‘There is a spill kit somewhere around here.’” The spill kit arrived about five minutes later after the blood-soaked items were already placed into the regular trash.

Other findings

Other state health department reports found:

● In October, 2010, the University of Toledo Medical Center was cited by the state health department, which did a survey of the hospital’s kidney transplant program based on findings by the Scientific Registry of Transplant Recipients. It “revealed that the actual one-year graft [transplant] survival rate was significantly lower than expected for patients transplanted between Jan. 1, 2007, and June 30, 2009.” The state’s report found “the expected number of graft failures was 13; the actual number of graft failures was 22.” Dr. Jeffrey Gold, chancellor and vice president for biosciences and health affairs at UTMC, said graft survival refers to the organ that was transplanted. Six out of the 22 patients died at some point and the others went back to other methods such as dialysis after kidney graft failure.

● In January, 2008, Toledo Hospital’s adult cardiac catheterization laboratory was cited. The state said doctors were supposed to perform only low-risk cardiac catheterizations in identified catheterization laboratories but some high-risk procedures were done.

A review of complications and transfers of patients whose cardiac catheterization were performed in the outpatient setting revealed five complications between Jan. 12, 2007, and Nov. 2, 2007. That included three patients who experienced neurological deficits during or immediately after the catheterization.

● Mercy St. Vincent was cited on Oct. 9. 2008, by the state health department because it “failed to ensure that medical records were completed within 30 days following discharge” and for fire safety problems. The same report cited the hospital for its “physical environment,” because a survey found areas of penetration in fire walls, missing fire pull stations, dirty sprinkler heads, improperly placed smoke detectors, gaps between smoke barrier doors, locks on patient room doors that would prevent exit from the room, a lack of exit signs, and missing sensitivity testing for smoke detectors.

● A Sept. 5, 2007, report on St. Luke’s Hospital found that nurses failed to document ongoing restraint assessments to justify the need for multiple restraints used concurrently to protect a patient. St. Luke’s was also cited in that report because the hospital did not ensure that four patients who were restrained had complete doctors’ orders for restraints.

● In April, 2005, Mercy St. Vincent Medical Center was investigated by the state health department acting on a complaint regarding illegible, incomplete, unauthenticated, and improperly dated entries. A doctor who saw a patient on Jan. 25, 2005, for shortness of breath, and to rule out lung cancer, did not date and time when the exam was completed.

● In 2003, Mercy St. Charles Hospital was cited for its use of restraints on patients.

Contact Ignazio Messina at: imessina@theblade.com or 419-309-0939.