DECH placed on ‘immediate jeopardy’ status after incident

State and federal regulatory agencies have released their findings in the most recent investigation of Down East Community Hospital (DECH), triggered by a complaint about the care provided to an emergency department patient on October 3-4, 2008. Within hours, the patient, identified only as "Patient A," was transferred to Eastern Maine Medical Center (EMMC) in Bangor, where he died on October 11.

According to a nine-page "summary statement of deficiencies," a team representing the Department of Health and Human Services (DHHS) and Centers for Medicare & Medicaid Services (CMS) visited DECH on March 10, 11 and 17-19 to review medical records, policies, procedures and protocols, and to interview key hospital staff.

With respect to Patient A, the team found that the hospital's emergency department: failed to recognize the life-threatening severity of the patient's presenting condition; failed to provide adequate stabilizing measures to prevent further injury; failed to transfer the patient in a timely manner; and failed to have adequate systems in place to identify patient care problems in the emergency department.

"These findings," the report states, "present an immediate jeopardy to the health and safety of patients served by the emergency department at Down East Community Hospital."

Accompanying the statement of deficiencies is the hospital's "Corrective Action Plan," a 204-page document that was approved by DHHS and CMS on April 3, according to Catherine Cobb, director of Licensing and Regulatory Services for DHHS. The plan specifies the standards and staff training that are required of DECH in the areas of triage ("categorizing emergency department patients into emergent, urgent and non-urgent categories"), patient assessment, patient stabilization, patient transfers and systems to identify problems. Completion dates are listed for each corrective action C all are ongoing or completed C with the title of the DECH staff member responsible for implementing it. In most cases, the chief of Emergency Services is designated as the responsible person, with the outpatient nursing director charged with ensuring compliance in the area of triage.

According to the report, Patient A arrived at the hospital at 9:45 p.m., transported by the Machias Ambulance Service following a fall at home down a flight of stairs. An assessment exam by the ambulance attendant had found the patient "unresponsive" with "labored" breathing. "In spite of having arrived in the emergency department unconscious, with pupils of unequal size and spasm-like contractions of [the] torso and legs bilaterally after a fall, Patient A was classified as urgent rather than emergent."

The hospital record states Patient A was seen by Physician A at 10 p.m. Despite the symptoms described, "there was no documented evidence a physical assessment or examination was performed on Patient A, other than one notation indicating a traumatic abrasion." The investigative report also states that "there was no documented evidence that Patient A's respiratory rate was monitored other than during the initial assessment completed at triage by the registered nurse and at 2212 [10:12 p.m.]"

Physician A did not follow "the acceptable standards of practice for a trauma patient," including assessment of consciousness using a standard coma scale. There was also no documented evidence that Physician A completed a neurological assessment, since the pertinent section of the medical record was left blank. When interviewed by the survey team, Physician A stated, "I didn't finish the whole chart. It was a mistake on my part. The neuro exam was done. I didn't mark it off. The same for the complete physical exam. It's not written so it looks like it wasn't done but it was." The report notes that Physician A also "denied documenting 'non-traumatic' under the clinical impression section of the emergency department documentation."

In interviews with the survey team, Physician A stated the patient "did not need to be intubated" on arrival. When the physician surveyor asked Physician A "if in retrospect he/she felt that Patient A could protect his/her airway," Physician A replied, "No." The report states, "In spite of the acceptable standard of practice for airway protection in a comatose patient being intubation, Physician A did not intubate Patient A." The patient was later "intubated by the Lifeflight crew two hours and 57 minutes after his/her arrival in the emergency department," presumably en route to Bangor.

In the course of gathering information about Patient A's treatment in the DECH emergency department, the survey team conducted a number of interviews with the hospital's director of Emergency Services, who stated, "This [patient] needed to be intubated right away." The director added, "This case demonstrates the way [Physician A] thinks like an internist [rather than an emergency physician.]" The director also stated the case of Patient A was "horribly documented," adding, "The thought was 'oh, this is a drunk.' I don't know where that thought came from."

Surveyors were concerned that "rapid transport to the most appropriate facility" was not accomplished, noting that contact by Physician A with EMMC is not noted in the record until "two hours and five minutes after he [Patient A] arrived in the emergency department unconscious after a fall."

As for the finding that DECH's emergency department failed to have an adequate system for identifying problems, the director of Emergency Services was interviewed about the process for diagnostic reviews of specific cases. The director stated that only cases related to "core measures" were reviewed. Core measures are statistics that hospitals collect in the categories of surgical care, heart attack, pneumonia and heart failure. He says he was told that "doing chart reviews was passé, and I was being 'old fashioned,' so we're not doing those reviews." Asked about efforts to identify problems, he replied, "Well, if you are finding that many patient concerns, then I agree, our systems don't work."

Director Cobb of DHHS said on April 6 that the surveyors were continuing to monitor the hospital with respect to the Immediate Jeopardy (IJ) finding. The IJ status remains, she said, "until we are satisfied the corrective action plan is in place and is working." In addition, she said, the DHHS team, acting on behalf of CMS, is conducting a "full federal survey" of the hospital that could produce findings as early as Friday, April 10. The findings would be made available when the hospital submits an acceptable corrective action plan for any deficiencies that may be found.

Roseanne Pawelec, a spokesperson for the Boston regional office of CMS, characterizes the IJ status as "very serious." Asked how often the federal agency has applied the term to hospitals under their jurisdiction, she researched the question before responding. From January 1, 2007, to the present, she said, there have been seven hospitals in New England that CMS placed in the "immediate jeopardy" category, not including DECH. In each case, the status was "resolved prior to termination" of the hospital's eligibility for funding under Medicare, Medicaid and other federal programs. The seven hospitals included four in Connecticut, one in Maine and two in Vermont, out of a total of 260 New England hospitals regulated by CMS.

Pawelec says a 23-day time frame is allotted for a hospital to clear an IJ status. In the case of DECH, the deadline would be April 15. If the hospital were unable to meet the standards for removal of the IJ classification, CMS would terminate the facility's Medicare-Medicaid approval. Even when such an extreme penalty is imposed, a hospital has an "appeal route" through an administrative law judge, Pawelec adds. The hospital remains under "conditional" licensing by the state as a result of previous complaint investigations conducted by the DHHS survey team.

Robin Popp, a DECH spokesperson, says the hospital is "very respectful of our regulators and wants to cooperate fully in their process. We will not be issuing any statement or responding to questions until the survey team has completed their work."