Risk Management Falls Under Criticism After a Patient is Forcibly Removed

Risk management at a Florida hospital was cited as insufficient in the state investigation following a high publicized incident in which a patient was forcibly removed, and the state rejected the hospital’s corrective action plan.

The state is seeking $45,000 in fines against Calhoun–Liberty Hospital in Blountstown, FL, following an incident in which 57-year-old Barbara Dawson refused to leave the hospital and was forcibly removed by a police officer. She collapsed outside and died from what the medical examiner’s office determined was a blood clot in her lung caused by obesity.

Dawson’s death received widespread publicity and prompted a probe by Florida’s Agency for Health Care Administration (AHCA), the state agency in charge of licensing and administering policy and planning for healthcare facilities. AHCA Secretary Elizabeth Dudek announced that the investigation found 10 deficiencies at the hospital, including deficiencies regarding patient rights and care, emergency services, and the risk management program – patient grievance analysis.

“Our Agency found the deficiencies at Calhoun–Liberty Hospital so egregious that the facility will be fined and is required to submit a Plan of Correction by February 19, 2016,” Dudek said. The hospital submitted a corrective action plan by that date, but AHCA rejected it. The Agency sent a four-page letter to the hospital’s CEO and administrator Ruth Attaway and said the facility’s submission included several unreadable pages and that the facility failed to specify numerous aspects of its plan.

The hospital was given a deadline of March 1 to correct the deficiencies, but AHCA did not announce any decision immediately after that date passed. If the agency determines the deficiencies were not corrected, the hospital will be suspended from the Medicaid program.

The hospital recently fired two nurses and a paramedic who were involved in the incident. They had been removed from patient care duties soon after the incident.

In addition, the former chief financial officer for Calhoun–Liberty Hospital filed a federal whistleblower lawsuit claiming the hospital’s board members did not stop harassment from the hospital’s former administrator. Haley Green filed the lawsuit in U.S. District Court for the Northern District of Florida, and Green alleged that she discovered fraudulent transactions for medical supplies by then director of emergency medical services Phillip Hill. Green claims Hill threatened her job and harassed her when she refused to overlook the alleged fraud.

The state’s report addresses two incidents that occurred in the Calhoun-Liberty emergency department (ED). The first involves a patient identified as no. 10, who was Dawson, the woman who was forcibly removed and subsequently collapsed outside the hospital. The second involves a patient identified as no. 23, a woman who requested pain medication in the ED because the medicine prescribed by her doctor was not working.

Calhoun-Liberty violated the state rule requiring a hospital to have written policies and procedures specifying the scope and conduct of emergency services with both patients, the report says. With Dawson, the hospital failed to follow its policies on medical screening examinations, respiratory distress evaluations, assessment, and change of condition assessment, investigators concluded. The report also indicates that the risk manager was out of state during the incident and when an investigator called her on some unknown date (interview dates are redacted in the report), she said she had not had the opportunity to speak with any of the staff members involved and had only begun a review of the medical record.

With the second patient, no. 23, hospital staff explained to her that the ED was staffed with only an advanced registered nurse practitioner (ARNP), rather than a physician, and the ARNP could not prescribe the pain medication because of another medication she was taking. The woman became angry and left the ED without seeing the ARNP. Agency investigators found no documentation indicating that the staff ever triaged the patient, obtained vital signs, completed a pain assessment, or conducted a medical screening exam.

The risk manager apparently did not learn of the no. 23 incident for at least three days after it happened. In the narrative detailing the incident and the investigation, the AHCA report notes that an investigator interviewed the hospital’s risk manager, who stated “that she had not been in at the time of the incident and had not known of the incident until yesterday, [date redacted], when she asked the administrator about it.”

The director of nursing told investigators that the ED always has a physician on call who can prescribe medications. The director said that it was not normal procedure to tell patients that the ARNP cannot prescribe a medication and that she would expect that conversation to take place between the patient and the ARNP.

The report cites the state’s requirements for an incident reporting system “based upon the affirmative duty of all health care providers and all agents and employees of the licensed health care facility to report adverse incidents to the risk manager, or to his or her designee, within 3 business days after the occurrence.” That requirement was not met, the report says, because “based on patient interview, staff interview, and record review, the hospital failed to implement their incident reporting system for two of 24 patients sampled to the emergency department (no. 10 and no. 23). The administrator failed to complete an incident report and initiate an investigation after receiving a complaint from patient no. 23 about being turned away from the emergency department, a violation of State Emergency Access Laws.”

The report states that by the end of its investigation, the hospital had not filed an adverse incident report with the state agency for the Dawson incident, as required within 15 days by state law. The federal component of the survey is under review by the Centers for Medicare and Medicaid Services.