The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on record review and interviews, the hospital's governing body failed to hold its physicians accountable for the quality of care provided to 2 of 10 patients, Patient #1 and Patient #7. The physicians failed to diagnose a damaged mitral (heart valve) for Patient #1 over a course of 36 days which included 4 Emergency Department (ED) visits. The hospital failed to ensure Patient #7 was medically stable before transferring her to fulfill a court mandated 30-day psychiatric hold. Patient #7's diminishing health status required two more transfers to other hospitals for a higher level of care. Patient #7 died at a fifth hospital.
The findings are:

A. Record review indicated Patient #1 saw her primary care provider (PCP) on 12/19/16 for shortness of breath and was prescribed an inhaler. The patient reported to both the PCP and Emergency Department physician she received no relief with the inhaler.

B. Record review of Patient #1's ED record dated 12/27/16 at Hospital #1 revealed the following:
1. A note dated on 12/27/16 at 13:00: "stated complaint of cough, SOB [shortness of breath]; weakness; ...Pt [patient] c/o [complains of] cough, SOB, wheezing and weakness since 12/19/16, Reports no relief with inhaler." The Physician Assistant ordered labs (blood work), a 2-view chest x-ray, and EKG [electro cardiogram, an electrical tracing of the heart], respiratory treatments including an anti-inflammatory medicine and a Computer Tomography (CT) of the chest with contrast (makes the test more detailed).
2. She was discharged home after her condition stabilized. The ED scheduled a follow-up appointment with her primary care provider (PCP) on 01/03/17.
3. Lab test BNP (B-type natriuretic peptide test is used as an aid in the diagnosis and assessment of severity of heart failure) performed on 12/27/16 was borderline at 436 pg/ml, suggesting congestive heart failure. A blood test (D-Dimer) was negative for deep vein thrombosis (blood clot).
4. A chest x-ray performed on 12/27/16 was positive for new small bilateral pleural effusions (collection of fluid around the sacks of the lung). Another finding of the chest x-ray was "upper lobe pulmonary vessels appear prominent suggesting pulmonary congestion. Pleural effusions may be related to mild congestive heart failure...Conclusions 1. changes consistent with COPD (Chronic Obstructive Pulmonary Disease) 2. Small bilateral pleural effusions and mild bibasilar atelectasis [air in the sacks that surround the lungs)] or infiltrate (fluid). 3. Pulmonary congestion." Pleural effusions are not part of a diagnosis of [DIAGNOSES REDACTED]
5. Results of the CT of the chest performed on 12/27/16 revealed the following conclusion,"negative finding from the pulmonary CTA" (Computed Tomography Angiography). This test injects a dye into the heart to amplify the visualization of abnormalities by the scan.
6. Review of the physician's physical assessment on 12/27/16 indicated no heart murmurs. The extra heart sounds of a ruptured heart valve are called a murmur or bruit.

C. Record review indicated the ED referred Patient #1 to her PCP for follow-up in one week, 01/03/17. During this visit the PCP ordered an Echo (ultrasound) of her heart. There was no record of the performance of the test; or a reason why it was not performed.

D. Record review indicated Patient #1 was seen in Hospital #1's ED on 01/13/17 and a consultation with a pulmonologist (a physician who specializes in lung conditions/diseases) was ordered. Patient #1 was seen by the pulmonologist on 01/26/17 and a Pulmonary Function Test (PFT) was performed. The results demonstrated no change in lung function. (Pulmonary function tests are a broad range of tests that measure how well the lungs take in and exhale air and how efficiently they transfer oxygen into the blood.)

E. Record review of the 2-D Echo (the ultra sound of the heart) report for Patient #1 performed at hospital #1 on 01/30/17 indicated the following:
"Atria (one of the 4 chambers of the heart): The left atrium is severely dilated the right atrium is moderately dilated...Mitral Valve: The mitral valve is moderately thickened but opens normally. THERE IS SEVERE PROLAPSE AND A PARTIAL FLAIL SEGMENT AT P2... THERE IS SEVERE "WIDE OPEN" [DIAGNOSES REDACTED]." ([DIAGNOSES REDACTED] is leakage of blood backward through the mitral valve each time the left ventricle contracts. The valves normally close with minimal leaking.)

F. Record review of the chest x-ray performed at Hospital #1 on 01/30/17 indicated a right pleural effusion (fluid) increasing. Review of the EKG indicated inferior/lateral ST-T (electrical cardiac) changes are non-specific and possible atrial (heart) abnormalities.

G. Record review of the Pre-hospital Care Report from Hospital #1 Emergency Medical Service (EMS) dated 01/30/17 indicated the following:
"EMS responded to an emergency call from the [Patient #1] residence at 05:09 am. The chief complaint was shortness of breath for 30 minutes with chest pain and body aches. She had increased the oxygen flow from 2 liters to 5 liters without any relief. She was transported to the Hospital #1 ED on 6 liters of oxygen. " Patient #1 was transferred on 02/01/17 to Hospital #2 for a higher level of care, surgery to replace her mitral valve in her heart, and a coronary bypass (to improve blood flow to heart) graft in two of her main coronary blood vessels. She was discharged from Hospital #2 on 03/06/17 ".

H. Record review of ED Physician #1's Medical Privileges at Hospital #1 revealed: "Consultation should be obtained for patients presenting with major trauma, cardiac or psychiatric illness. In situations when a diagnosis remains in doubt, when treatment remains ineffective or patient's condition continues to deteriorate, physicians are expected to obtain appropriate consultation."

I. On 04/20/17 at 1:30 pm during interview via phone, the daughter confirmed the following concerns with the care her mother received at Hospital #1: Patient #1 came to the ED complaining of a sudden onset of respiratory distress on 12/25/16, especially on exertion (activity).
She stated, "While she had chronic obstructive pulmonary disease (COPD) from her 50 pack year [1 pack per day for 50 years] smoking, she never needed oxygen before this event. It was not resolving at home so she came to the ED on 12/27/16. [Patient #1] had an oxygen saturation of between 70 and 80 percent. [Normal would be in the 90 per cent range.] She was treated with inhalers. Later on 01/30/17 I pushed the Pulmonologist to not send her home again without doing the Cardiac Echo. "

J. On 04/21/17 at 11:00 am during interview, the daughter stated the surgeon at Hospital #2 expressed to the family that [Patient #1] had the heart valve problem for a month. Patient #1 arrived at the [Hospital #2] with a serious fluid overload which required 4 days of diuretic treatment (medicine that increases urination) to prepare her for surgery. She also had significantly elevated pulmonary hypertension (blood pressure in the lungs).

K. On 04/21/17 at 1:30 pm and 1:45 pm respectively during interview, both the pulmonologist and the cardiologist, who both consulted for Hospital#1's ED, were asked why they understood Patient #1's clinical status, i.e., the [DIAGNOSES REDACTED], and the ED physician did not. Both stated each had "greater skill in this area" than the ED physician.

Patient #7:

L. On 01/27/17 at 10:00 am during interview, the power of attorney (POA) of Patient #7 identified the following concerns:
a. The POA called the Emergency Transport Service which brought Patient #7 to Hospital #1 ED in the hopes of obtaining a mild sedative for Patient #7.
b. The POA did not agree with the psychiatric holds and he did not agree with the transfer to Hospital #3 from Hospital #1.
c. He thought the hospital over-sedated Patient #7 with Haldol (a sedative).
d. He was generally appalled about the care she received from all of the hospitals and felt that the "system failed her and killed her."

M. On 04/21/17 at 11:10 am during interview, the discharging psychiatrist, Physician #2, stated, "I delegated the medical screening exam to the hospitalists." Hospitalists are physicians that focus on the medical problems of a patient. She was asked if the Hospital had a choice to transfer or not. She stated, "We don't have a choice when the court mandates the transfer. "She was then asked, "what if the patient was medically unstable?" She replied, "We thought she was stable. We sent her by ambulance instead of by sheriff car."

N. On 04/20/17 at 3:15 pm during interview, the Director of Nursing at Hospital #1 confirmed that the last EKG for Patient #7 was performed in the subacute care unit or SCU on 08/09/16 and no cardiac consultation was ordered during the length of her stay.

O. Record review of Patient #7's medical record at Hospital #1 indicated an EKG performed on 08/08/16 when she was transferred from the Behavioral Unit to the SCU (Step-down Care Unit) to stabilize markedly elevated blood sugars (over 800 mg/dl - Normal blood sugar is between 80 and 120 mg/dl.) The EKG indicated an abnormal heart rhythm. No referrals to a cardiologist were found. Review of a previous EKG dated 01/01/16 indicated a possible inferior infarct, a loss of heart muscle from lack of blood flow, age undermined EKG tracings from the SCU indicated depressed ST segments and inverted T waves, both abnormal findings. A blood test, the HgA1C that measures blood sugar levels over 90 days, indicated a result of 12.3 % where a normal value would be between 4.8 and 5.6. This indicated Patient#1's blood sugar was markedly out of control for at least 90 days.

P. Record review of the medical record of Patient #7 at Hospital #1 indicated the following:
"Discharge Summary: [Patient #7] discharge date [DATE]. Discharge Diagnoses: Major neurocognitive impairment related to dementia, severe; insulin dependent diabetic. History of Present Illness: The patient was transferred from the SCU [subacute care unit] when she was medically stable. She had developed a diabetic ketoacidosis [DKA, a serious condition that can lead to diabetic coma or death; when blood sugar is too high]. She was stabilized and transferred back to the Behavioral Health Unit. She continues to require line of sight [supervision] and at times one-to-one because she continues to wander around the unit and go into other people's rooms thinking that there are multiple people living in her house and thinking she needs to get them out of her house. She requires p.r.n. [as needed] at bed time and we are having to give her Lantus [insulin] and do Accu-Cheks [glucometer] even if she is refusing them to prevent diabetic ketoacidosis. Hospital Course: The patient was readmitted to the Behavioral Health Unit on a 7-day involuntary hold. We planned to look for a nursing home placement for her. The patient continued throughout the hospitalization to be aggressive and requiring one-to-one. We got up to a 30-day court commitment granted to [Hospital #1] and tried working with medications but patient's aggression continued. The patient was not accepted by any nursing home because of her aggressive behaviors and at the end of the 30-day court commitment we were faced with an extended commitment to the [Hospital #3]. Since the patient is unsafe to be discharged home, even in the care of her POA, we had to go ahead and request the extended court commitment as the patient still was not accepted by any nursing home, most likely because of her behaviors. On 08/31/16 the patient was transferred to [Hospital #3], for extended court commitment to buy more time to continue to stabilize the patient and get her into nursing home setting."

No lab results except an extensive list of wide ranging blood sugars were included for her length of stay in the behavioral unit from 08/03/16 to 08/31/16. The range was from 54 mg/dL to 473 mg/dL. No other clinical data including electrocardiogram, electrolytes, x-rays, blood or urine cultures, input and output data to assess hydration, or any other clinical data was supplied in the discharge summary and transfer. An EKG was performed on 08/08/16 on admission to the Hospitals subacute care unit. A possible inferior infarct (loss of heart muscle)-age undetermined was again indicated.

Q. Review of the medical record of [Patient #7] at [Hospital #5] indicated the following:
1. Admission History & Physical at [Hospital #3] on 08/31/16:
"Identifying Data: The patient is brought to [Hospital #3] in restraints on a gurney from [Hospital #1].
Presenting Complaint: She is a 68-y/o [year-old] female who was living at home with home health care aides who were alienated by her aggressive behavior and left which resulted in the patient being sent to the emergency room where she was transferred to this facility for psychiatric care. This is primarily due to her aggressive hostility towards care providers."
2. Review of the [Hospital #3] Medical Discharge Summary dated 09/05/16 indicated the following:
Date of admission: 08/31/16
Date of discharge: 09/05/16
"Discharge diagnosis for Psychiatry: Major neurocognitive disorder with evidence of delirium (state of confusion that occurs abruptly).
Hospital course: Hospital course [Hospital #3] was medically difficult because of high blood sugars with resistance to control by repeated doses of Humalog (short duration insulin); therefore, the patient was discharged from [Hospital #3] to [Hospital #4]. Assessment in the emergency department resulted in a need for inpatient hospitalization for issues regarding her neurocognitive events, diabetic issues and metabolic (fundamental cell function) issues including hypernatremia (elevated sodium in the blood) as well as hyperglycemia (elevated sugar in the blood) noted at [Hospital #4]."

R. Review of the medical record for Patient #7 at [Hospital #4] admitted [DATE] and discharged [DATE].
"Transfer diagnosis: Altered Mental Status Admitting Diagnoses: Metabolic [DIAGNOSES REDACTED] (altered brain chemistry), Baseline dementia, Acute Coronary Syndrome (high level Troponin) [heart muscle enzyme indicating a heart attack] with EKG [heart rhythm] changes, Mood Disorder, Undifferentiated, Diabetes Mellitus, dementia, dehydration."
Discharge Summary: "Dated 09/13/16. Chief Complaint: Altered Mental Status. Final Diagnoses: Generalized seizure; x 2 in past 36 hours, status post tele neurology consultation recommending transfer to tertiary [specialized] facility for neurology, patient loaded with 1 g[ram] Depakote (seizure medicine) this a.m.; Chronic combined systolic and diastolic heart failure, Ejection fraction 30-35 per cent [normal ejection fraction is 50-55 %], blood glucose abnormal, mood disorder undifferentiated, leukocytosis [increased leukocytes in blood suggesting infection]; metabolic [DIAGNOSES REDACTED] [altered brain chemistry]; CT [computed tomography, detailed x-ray of the brain]; chronic pain; Diabetes mellitus [uncontrolled blood sugar], elevated Hemoglobin A1C [indicates elevated blood sugar over a 90 day period]; Dementia." "Hospital Course: [AGE] year old female who was transferred from [Hospital #3] for altered mental status. Patient was transferred from [Hospital #1] 1 week prior to that; apparently admitted there for altered mental status and she developed DKA [Diabetic Ketoacidosis, a metabolic acidification of the blood caused by elevated blood sugar and dehydration] while she was there. No other psychiatric diagnoses documented other than dementia. Of note her power of attorney is very knowledgeable and caring individual. She is DNR [do not resuscitate]. Her behavior and moods fluctuate significantly. She will intermittently respond to commands and she is frequently uncooperative and his{sic}currently only on Haldol per my discussion with her psychiatrist at the state hospital. We were considering transfer back to the state hospital as of 3 days ago but did not do so due to her labile (changeable) blood glucose between 50 and 450. Approximately 36 hours ago she had a generalized seizure lasting 45 seconds had a postictal state [confusion and slow mental activity after seizure] and a blood glucose of approximately 250. A tele neurology consultation was performed and suggested the possibility of nonconvulsive [DIAGNOSES REDACTED] (state of confusion and impaired consciousness) and recommended transfer to tertiary facility where EEG [electroencephalogram] and neurology services were available."

S. Record review of the medical record for [Patient #7] at [Hospital #5], indicated the following:
1. "Admission H & P [History and Physical]; Chief Complaint: Altered mental status, seizures. History of Present Illness: 68 y o F sent from [Hospital #4] for seizure, history is very limited a patient unable to provide history and even in [Hospital #4] she was AMS [altered mental status] so they were not able to get much history either. But apparently {sic}she was initially in [Hospital #3] for Dementia with behavioral disturbance, on Cogentin [used for bipolar disorders] and Haldol [sedative], she then developed acute [DIAGNOSES REDACTED] and sent to [Hospital #2], there she was noted to have elevated Troponin [a specific heart muscle enzyme that can be found in the blood which indicates loss of heart muscle] and a cardiologist was consulted an ECHO [ultra sound of the heart] showed ER ,d+[DATE]% [ejection fraction the measures the output of the heart, normal is 50-55%] with wall motion abnormalities [stiff heart muscles that reduce output] and stress test was planned but could not be performed due to patient not being cooperative. It was decided to continue with conservative management, statin [anti-cholesterol medicine]/ASA [aspirin]."
"Notes indicate patient was agitated and intermittently restrained. She then developed seizure tonic clonic 2 in 24 hours and Tele neurology was consulted who recommended transfer for further evaluation here... on arrival BP [blood pressure] 70/30 [normal blood pressure is 120/80]....Assessment and Plan: Acute [DIAGNOSES REDACTED]- likely related to seizures, postictal?, failed swallow, keep NPO [nothing by mouth], speech eval, Neurology evaluation, supportive care, try to avoid CNS acting medications, Seizure- loaded with Depakote...dementia- hold cogentin and haldol for now, Diabetes mellitus type 2 uncontrolled,..[DIAGNOSES REDACTED], CAD (coronary artery disease)."