A two-day investigation by state officials conducted last week at Southwestern Vermont Medical Center indicated that two nurses in the hospital’s Emergency Department failed to provide adequate care by not responding to an immediate change in the condition of a patient who died unexpectedly.
The hospital itself reported the incident to the state on October 2, and state surveyors conducted an official inquiry on October 7. The state, which acts as a proxy for the federal Centers for Medicare and Medicaid Services (CMS), also indicated that hospital policies were not followed including those related to privacy, obtaining consent for treatment, and immediately reporting adverse events.
‘I am upset and disappointed that we did not live up to our own high standards for the care that we provide and that our community expects,’ said Thomas Dee, president and CEO. ‘We are committed to being transparent with regulatory agencies, our staff, patients and families, and our community. To that end, we reported the incident ourselves. We already have taken steps to see that this does not happen again, including ensuring that the two nurses involved in the event are no longer treating our patients. In addition, we have discussed the incident with the family and offered them our apology and our help in understanding what happened and the steps we have taken to address the problems.’
At the center of the investigation is an incident of a patient who arrived at the SVMC emergency department with a complaint of back pain. Following the patient’s initial assessment, a non-clinical staff member found that the patient showed no signs of life and notified both nurses caring for the patient. Neither nurse immediately checked on the patient. A few minutes later, the nurse in charge also noticed that the patient showed no signs of life, and she immediately called a physician. At present, the cause of death is unknown. An autopsy has been ordered, but the results are not yet available.
Dee said CMS is expected to cite the hospital for failing to maintain proper standards, which could result in SVMC’s losing its ability to participate in the federal Medicare program. He explained that this type of citation is common in situations as serious as this one. Such a citation would require the hospital to immediately correct the deficiencies. CMS would then conduct a follow-up visit to determine if the hospital has successfully corrected its problems.
‘We take this event very seriously,’ Dee said. ‘Even before the officials had left the building, we had begun to correct the problems to ensure that our community can continue to trust our emergency department for their care.
‘We look forward to demonstrating our commitment to superior patient care and safety at a follow-up survey. At this survey, we expect CMS to accept our plan of correction and certify that SVMC remains a full participant in compliance with Medicare’s standards.’
Dee explained that hospital management immediately took several steps to address the incident with more changes expected soon. To date, SVMC has
Restructured nursing leadership overseeing the emergency department
Developed a system for ensuring that strong leadership is present in the Emergency Department on all shifts
Held immediate educational discussions with clinical staff throughout SVMC to reinforce the culture of patient safety, the duty to immediately report and identify unsafe behaviors or conditions, and to review SVMC’s system for reporting such events
Instituted a requirement for health system staff to undergo intensive, interactive education sessions on patient safety and hospital policies including informed consent and privacy.
‘This event is a clear call to action,’ Dee said. ‘Our entire team, throughout the health system, will not rest until we see SVMC return to full compliance with Medicare. We are confident that this incident does not reflect the quality of our staff or the care that we provide, and we are determined to demonstrate this fact to our patients and their families going forward.’
Source: SVMC 14 October 2013