Deficiencies at hospital cited in investigation of man's death

In the wake of the death of a 61-year-old Eastport patient one month ago, a subsequent investigation by the U.S. Department of Health and Human Services' Centers for Medicare and Medicaid Services (CMS) has determined that the Down East Community Hospital (DECH) in Machias must correct a number of Medicare deficiencies and submit an acceptable plan of correction. Reid Emery's body was found on January 2 partially buried in snow near the Machias hospital after he had checked himself out during a snowstorm the night before.

After reviewing the 24-hour patient care flow sheet, including the codes used in the psychosocial section, nursing supervisor worksheet, a medical record, the timeline of events and background information, and conducting interviews with staff and physicians on January 3 and 4, investigators "determined that the governing body or individual that assumed full legal responsibility failed to determine, implement and monitor policies governing the CAH's [Critical Access Hospital's] total operation and for ensuring those policies were administered so as to provide quality health care in a safe environment."

According to the report, Emery had been suffering from chronic abdominal pain since the summer and had been diagnosed with anxiety/depression. He was taking several medications.

A doctor who worked from 8 a.m. until 8 p.m. on New Year's Eve told the CMS investigators that, on New Year's Eve, Emery was getting Demerol every hour and requesting it adamantly. When the nursing staff called saying Emery was screaming in pain, the doctor increased Emery's Demerol. The physician received a call from Emery's wife, Margaret Emery, and, after speaking with the nurses, increased Reid Emery's Fentanyl patch. When the nurses called again to say the patient was still having pain, the physician ordered a Dilaudid IV as well as Seroquel to help him sleep.

On January 1 at 12 p.m., a second physician noted that Emery was still in pain and requiring large amounts of narcotics, at least three of which cause clouded senses, while two cause sedation and somnolence, one causes confusion and one causes paradoxical anxiety.

The doctor on duty on January 1 reported that Emery's pain medications were decreased. The doctor then got a call from a nurse saying Emery was agitated and thought he had AIDS. The doctor says that, subsequently, "The supervisor called me to tell me [Emery] wanted to leave AMA [against medical advice] and that [he] was competent."

A nurse on duty that day told CMS that she notified the doctor that Emery was "acting suicidal," but the doctor denies knowing that.

The CMS report states, "In spite of the evidence that the patient had a history of anxiety/depression, had been given multiple doses of medications with the potential side effects listed above, and had expressed that he/she believed he/she had AIDS, [the doctor on duty] stated that he/she told supervisor #2 to have the patient sign an AMA form and call the police if there was a problem."

In an interview conducted with a second nurse on duty the night of January 1, the nurse told CMS that Emery said he had AIDS and wanted to get out of the hospital. "I told [Emery he] needed to sign an AMA form and [Emery] then pulled out the IV tubing. I told [him] it was snowing out. I said we walk people out to the car. [He] said [he] didn't need a ride because [he] knew someone near by. I gave [Emery] his bag of belongings, and I saw no sign of weakness. I was leaving when [Emery] stood and put on his pants."

The report says there was no evidence that the physicians followed Down East Community Hospital policy entitled "Discharge of Patients" and did not assess the Emery for competence and explain to him the risks of leaving the facility against medical advice. It appears that the nursing staff failed to follow "Suicide Precautions," "Automatic Referral of High Risk Patients," "Hand Off Communication" and "Discharge of Patients" policies.

Consequently, Wayne Dodwell, president/CEO of the Machias hospital, sent a plan of correction on February 1 addressed to Richard Shaw at CMS. The accompanying letter reads, in part, "DECH takes its responsibilities for assuring patient safety very seriously. Even before receiving your letter, DECH was in the process of implementing aggressive measures to address the issues it had identified to improve patient safety measures and to assure, among other things, that all DECH processes relating to the assessment and discharge of patients wishing to leave the hospital against medical advice will meet or exceed the applicable requirement of the Medicare Conditions of Participation."

Dodwell released a statement on February 6 in which he stated, "In addition to cooperating fully with government agencies, we have also completed our own review of the events surrounding Mr. Emery's stay at our hospital. Because this matter may be involved in the legal process, and respecting the laws that govern the confidentiality of patient information, we are not able to comment further on the details of our internal review."

Roseanne Pawelec, spokesman for the Boston regional office of the CMS, says the next step is to evaluate Down East Community Hospital's plan. "If it's acceptable, we'll be making a surprise follow-up visit to ensure what DECH said it will do has been implemented."

Machias Police Chief Grady Dwelley says his department is still investigating Reid Emery's death. Dwelley has been chasing down possible witnesses during the past month and has traveled out of town to interview several. "The one time we don't talk to somebody, that'll be the one we should have," he says of the trips.

As of the morning of February 6, Dwelley had not seen the Centers for Medicare and Medicaid Services report listing ways the hospital was out of compliance with Medicare conditions of participation.

"I've got to make sure what I'm reading isn't an interpretation by the reporter and the editor," points out Dwelley of an article that ran in a daily newspaper on February 6. "When I get the actual report, basically, I'll compare and see what's accurate. People will tell you things in the heat of the moment; then information gets filtered through several people."

Dwelley says he is still waiting for the results of the autopsy report from the state medical examiner's office, "but that might take up to six months."