Sarasota hospital facing fed review after ER mishaps

dgulliver@bradenton.comAugust 26, 2011 

SARASOTA -- Sarasota Memorial Hospital, the region’s health care giant and nationally known for its quality of care, faces a major review after state inspectors found hospital staff made mistakes in eight emergency room cases.

The inspectors cited the hospital for failing to prevent patient neglect and for failing to meet standards for nursing care, emergency care and accountability.

According to the inspectors’ report and hospital sources, the investigation resulted from the case of a young woman, diabetic and 13 weeks pregnant with twins.

The woman came to the emergency room at around 9:45 a.m. July 1, reporting pelvic pain and vaginal bleeding. The report refers to her as “Patient #5”; it does not identify the patient or any staff by name.

Over the next eight hours, the woman lost both fetuses. Meanwhile, medical staff failed to promptly perform some necessary tests, including a six-hour delay in measuring the patient’s blood-sugar level, according to inspectors from the state Agency for Health Care Administration. They reviewed the case when they visited Sarasota Memorial on Aug. 8 and 10.

According to their notes, the case unfolded like this:

By 10:30 a.m., the patient was diagnosed with pain and bleeding, her pregnancy and implanted insulin pump were noted and a urinalysis and a battery of blood tests ordered. But there was no test that would have measured her blood-sugar level, and case records show no discussion of whether to discontinue or maintain the insulin pump’s operation. A staff member ordered the wrong ultrasound tests, which radiology canceled. Re-ordering the tests caused a delay.

By 11:45 a.m., the doctor had the radiology department’s ultrasound scan, which showed both fetuses had normal heart rates. Meanwhile, the nurse noted that the patient was bleeding heavily. “The patient was in obvious labor and the ECC physician failed to initiate any immediate response to the ultrasound report, the patient’s continued labor pains and the profuse bleeding,” inspectors wrote.

At 12:25 p.m., the physician performed a pelvic exam, with suction, assisted by the nurse. The patient passed large blood clots and “spontaneously aborted one of the fetuses during the procedure,” inspectors wrote. Case records show no indication the patient was informed of any risks or gave informed consent, they wrote.

By 2 p.m., the patient had returned from a second ultrasound, showing a normal heartbeat in the remaining fetus. Case records show the doctor took no steps to stop labor or maintain the second pregnancy. In his dictated notes, the doctor said the test showed the second fetus had no heartbeat, which was inconsistent with the radiologist’s report, inspectors said.

Around 3:30 p.m., the patient’s nurse was assigned another case involving a heart patient, which further delayed a blood-sugar test, inspectors said.

At 4 p.m., staff performed a finger-stick test to measure blood-sugar level. The result was “critically low,” inspectors said, and medical staff gave her orange juice orally and a dextrose solution intravenously.

At 5:30 p.m., the patient’s obstetrician arrived and performed a pelvic exam, but ordered no procedures or medications. Around 45 minutes later, the patient’s mother reported the woman passed the second fetus.

It is unclear whether physicians could have changed the outcome.

Dr. Aaron Sudbury, a Bradenton obstetrician who has no relation to the case, said the patient’s symptoms at 13 weeks indicate a “threatened miscarriage.” Labor-slowing drugs are ineffective, he said, and a fetus born at that stage cannot survive. “There’s nothing you can really do to alter that,” he said. The patient’s diabetes also put her at high risk, he said.

The hospital said it was still reviewing the report, but added that it already had started a system-wide review of its practices.

“We value AHCA’s thorough review and their recommendations for improvement,” said Sarasota Memorial CEO Gwen MacKenzie. “While federal/state law prohibits us from sharing information on specific patients, we want the family and community to know that this situation does not reflect the high standards of care we provide at our hospital, and we deeply regret the pain and anguish experienced by this family. Their situation brought to light a problem we were not aware of, but fortunately one we have the resources, expertise and wherewithal to correct.”

During their visit, state inspectors reviewed that case and 10 others that involved patients admitted with vaginal bleeding. They found problems in eight cases, largely in nurses failing to document the patients’ blood loss and failing to record vital signs and other case information.

Those documentation errors and the case of Patient #5 led to inspectors’ finding of neglect, which Medicare defines as the failure to provide services that would prevent physical harm.

The failure to assess fetal and diabetic stress and the documentation errors led to the findings of inadequate nursing and emergency care. The accountability finding came from Patient #5’s case.

Inspectors said that taken together, the mistakes indicated a serious problem.

“The cumulative effect of this lack of oversight and systemic issues resulted in the Nursing Service’s inability to ensure the facility maintained the provision of quality health care in a safe environment,” the state AHCA inspectors wrote. “This has the potential to affect the health, safety and well-being of all the patients the hospital serves.”

The state inspectors forwarded the findings to Medicare’s parent agency, the Center for Medicare and Medicaid Services. In an Aug. 23 letter, the federal agency found that Sarasota Memorial was not in compliance with standards for participating in the program.

The letter, dense with bureaucratic language, is a sort of warning shot from the agency. It can revoke a hospital’s right to receive Medicare reimbursements, which would be a fatal blow. Most hospitals rely heavily on Medicare payments, including Sarasota Memorial. More than half of its $461.7 million in net patient revenue last year came from Medicare.

But the agency rarely takes that drastic step; it has not terminated a Florida hospital’s Medicare participation in at least five years, and in most years terminates less than five hospitals nationwide, an agency spokeswoman said.

Instead, the letter is intended to press the hospital to improve its operations, which Sarasota Memorial said it is committed to do.

If a hospital is unresponsive, Medicare can issue a notice of termination, which sets a sort of countdown. The agency has not done so in this case, the spokeswoman said.

Sarasota Memorial’s next step is to submit a plan of corrections to the state agency. Then, in the next 60 days, state inspectors will conduct a top-to-bottom review of hospital operations.

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