Johnston Health is unlikely to face federal penalties after a patient in the emergency room flatlined for about 10 minutes with no one noticing.
On Aug. 25, 2013, a 66-year-old female patient died in the ER in Smithfield after the nurse watching her improperly left to care for another patient, according to an investigation by a federal agency. When the patient flatlined, none of the six people in the ER noticed for about 10 minutes.
But the federal government likely won’t suspend Medicare reimbursements to Johnston Health for that incident and for other lapses, including administrative violations and an incident involving another patient. That’s because Johnston Health has fixed its flaws to the government’s satisfaction.
Last year, the federal Centers for Medicare & Medicaid Services sent two letters to Johnston Health outlining two separate investigations.
The first letter, dated Oct. 21, outlined a number of ways in which Johnston Health did not meet the “conditions of participation” to allow it to receive Medicare funding. The letter gave Johnston Health a deadline: Fix the problems or lose Medicare reimbursements starting Jan. 19. Medicare reimbursements make up roughly 40 percent of the hospital system’s revenue from patients.
The letter detailed three problems:
• A case in December 2012 when hospital staff failed to properly screen a patient before sending the patient by ambulance to a hospital in another county. The patient, a woman, died 10 days later at another hospital.
• Two cases in which the hospital should have responded in more detail to patient complaints.
two head nurses, one over the Smithfield hospital and one over the Clayton hospital, instead of one nurse over both.
The second letter, dated Nov. 1, outlined the incident in which the patient died after no one noticed her cardiac monitor flatlining for about 10 minutes. The Centers for Medicare & Medicaid Services, or CMS, deemed that an “Immediate Jeopardy” situation, meaning a medical provider’s lack of compliance had caused, or was likely to cause, “serious injury, harm, impairment, or death to a resident.”
The investigators characterized the cardiac-monitor incident this way: “These deficiencies have been determined to be of such serious nature as to substantially limit your hospital’s capacity to render adequate care and prevent it from being in compliance with all the Conditions of Participation for hospitals.”
But by the time CMS investigated, Johnston Health had already put in place new rules and technology to keep such an incident from happening again. The Immediate Jeopardy situation was “abated on site,” meaning the hospital had already corrected the problems.
Five days after the incident, on Aug. 30, Johnston Health started a “root analysis survey” to learn on its own what happened and began taking corrective steps. Staff finished the survey on Oct. 17. Chief Executive Officer Chuck Elliott would not make the survey public, citing a federal law that allows it to remain private because it was peer reviewed.
CMS returned to the hospital last week to make sure Johnston Health was sticking to its changes. When they left, investigators said things looked favorable for Johnston Health, Elliott said. But the hospital won’t know for sure until it receives the official report from CMS.
Elliott declined to speculate on the effects of losing Medicare. But losing 40 percent of its patient revenue would likely cripple the hospital’s ability to treat patients and pay staff.
Hospital officials do not know who filed the complaints that led to the CMS investigations.
‘This situation should not occur’
The investigation into the cardiac death detailed what Johnston Health spokeswoman Suzette Rodriguez called a “system failure.”
At 10:48 a.m. on Aug 25, 2013, a 66-year-old woman arrived in the Smithfield ER via ambulance with complaints of low blood sugar and altered mental status. The following account comes from CMS investigation files. The woman’s name and the names of the medical personnel involved were redacted.
When she arrived in the ER, the woman had a dangerously low blood sugar. The medical personnel began treating her immediately. By 11:12 a.m., the woman was drinking orange juice. By 11:30 a.m., she was eating “a few bites of a meal,” and her blood sugar was low but climbing by 11:58 a.m.
At 1:27 p.m., the woman’s primary nurse, Nurse One, went to get lunch. He handed the patient off to another nurse, Nurse Two. When Nurse One came back from lunch about 30 minutes later and checked on the patient, she was flatlining. Nurse One called for help and medical staff in the ER tried to revive her but couldn’t.
At some point in the half hour when Nurse One was at lunch, Nurse Two took another patient upstairs. She was supposed to tell someone if she left the area but didn’t.
“I decided to take my other patient upstairs, and I don’t think I told anyone I was leaving,” the nurse told CMS investigators. “No alarms were sounding when I left. When I returned, everybody was in (the patient’s) room.”
Cardiac monitors in patient rooms are linked to monitors at the charge nurse desk in the middle of the ER. But “the charge nurse was on lunch, and nobody was watching the monitors,” Nurse Two told investigators. “I have never been told at (the hospital) who was supposed to watch the monitor. I don’t know whose job that is.”
Elliott, the CEO, said Nurse Two “shouldn’t have left the patient.” But citing personnel law, hospital officials declined to give her name, her level of experience or say whether she was disciplined for the incident. But emergency department staff underwent additional training after the incident.
A total of 10 people were on staff in the ER at that time: a doctor, a physician’s assistant, six registered nurses, a nursing assistant and a secretary. Two nurses were out to lunch, and two nurses were busy with patients. The other six staff members were in the ER at the time, but none heard the cardiac monitor flatline.
Elliott confirmed that the alarm was definitely on. Hospital officials could not explain how no one else in the ER heard the alarm go off for about 10 minutes.
Ultimately, the responsibility was on Nurse Two to report to another nurse to watch the patients under her care if she left the emergency room. But as Nurse Four explained to investigators: “Typically the charge nurse was supposed to watch the monitor along with whoever else. Everybody is responsible to monitor the alarms.”
And as the doctor in the ER explained: “Nursing staff are responsible for watching the monitors. This situation should not occur. No one should be in asystole (flatlining) and no one know it for 10 minutes.”
When asked whether the hospital had told the family the circumstances of the woman’s death, Elliott said he believed so but would have to check. Other hospital officials later said they could not release that information because of patient privacy.
Johnston Health’s response
Officials have stressed that the emergency rooms, in both Smithfield and Clayton, are safer than ever before, thanks to changes made after the patient death.
The charge nurse in the emergency department must now continuously watch the monitors through a central monitor; when leaving the area, the charge nurse has to sign a log book noting that he or she has handed the monitoring duty to another person.
Also, Johnston Health brought in Spacelabs, the vendor for the cardiac monitor, to make sure the alarms could never be turned off or turned down in volume to become inaudible. And the hospital linked the emergency department’s monitors to the ICU’s central monitoring station, where ICU staff also now watch the monitors, creating a redundancy.
Emergency department staff were trained on the new set-up. “There were measures put in place after to make sure it could not happen again,” Elliott said.
As for the patient diverted to another hospital, Elliott said the doctor in the ER told EMS to take the woman to the hospital where she had had surgery previously. Elliott said the doctor made a medical judgment. If the patient had arrived at the Smithfield hospital, it would have sent her to another hospital anyway because the Smithfield hospital wasn’t qualified to treat her condition.
Since then, hospital staff has had more training in medical screening and the hospital’s diversion policy.
Johnston Health also added a chief nurse over both ERs and changed its policies to make sure staff handles grievances properly.
News researcher David Raynor contributed to this report.