HJBR Jul/Aug 2019

Heart Failure 22 JUL / AUG 2019 I  Healthcare Journal of baton rouge   and possibly subsequent death”and ordered the hospital to make immediate fixes while the inspection was still ongoing. The hospital complied, avoiding the immediate loss of Medicare funding. This week, having been presented with the com- plete deficiency report, the hospital submit- ted a detailed plan of correction that Lawson said should bring St. Luke’s into compliance with federal standards. When the Chronicle and ProPublica first detailed problems with the heart transplant program last year, St. Luke’s executives said any issues had been corrected and stressed that they did not affect the hospital as a whole. Executives also took out full-page newspaper advertisements touting the hos- pital’s quality. Lawson’s more recent com- ments acknowledged the depth of the hospi- tal’s troubles and promised to address them. “This is a challenging time for our hospi- tal,” Lawson wrote Friday. “While we can- not change the past, we can continue to do everything possible to provide the highest quality, safest possible care and to do sowith compassion. I remain confident that Baylor St. Luke’s will emerge stronger than ever.” Reporters requested an interview with Lawson or other hospital leaders following the release of the report, but David Gonza- lez, of Pierpont Communications, a Hous- ton public relations firm, said they were not available. it led the St. Luke’s board of directors to replace three top executives in January, including the hospital’s CEO. The officials did not respond to requests for comment at the time. The fatal mistake followed a pattern of blood labeling errors at St. Luke’s, according to a report from theMedicare agencymade public in February. The review prompted the government to order a top-to-bottom inspection of the hospital. That inspection spanned more than two weeks in late March and early April, after new hospital leaders had already begun implementing reforms, and covered every aspect of care at the 850-bed facility. The hospital, long regarded as one of the best in the nation for heart surgery, is owned by Catholic Health Initiatives, a behemoth national nonprofit hospital chain, and co- managed by Baylor. In a letter posted on the hospital’s website Friday, hospital CEODoug Lawson pledged tomake additional changes needed to regain the trust of patients. “The conditions described in the CMS report did not occur overnight, nor were they the result of any single factor,” Law- son wrote. “We take the issues CMS iden- tified seriously and we owe it our patients and their families to correct them immedi- ately — and we have already started to do so through our internal quality program.” Some of the deficiencies — those related to infection control, patient safety and food services —were so serious that federal regu- lators concluded they “placed all patients at risk for the likelihood of harm, serious injury, members weren’t always following proto- cols needed to prevent air from seeping into the blood of patients receiving dialy- sis, a potentially fatal complication. In area after area, from infection control to quality assurance, from the kitchen to the executive suite, inspectors found that hospi- tal administrators didn’t have adequate pro- cesses in place to ensure the staff always followed safety standards and learned from serious mistakes. Those findings were detailed in a 203- page deficiency report from the Texas Department of State Health Services and the Centers for Medicare andMedicaid Services, which was delivered to hospital leaders last month and made public Friday. The report follows months of scrutiny by federal regulators and comes one year after the start of an investigation by the Hous- ton Chronicle and ProPublica that revealed a high rate of deaths and complications fol- lowing heart transplants at St. Luke’s. Sub- sequent stories uncovered other concerns related to surgical outcomes, hospital man- agement and nursing care. The Medicare agency cut off funding for heart transplants at St. Luke’s in August, prompting officials at the hospital and its affiliated Baylor College of Medicine to bring in new cardiac surgeons to lead the program and begin an ongoing effort to regain fed- eral certification. But the government scrutiny of St. Luke’s broadened a few months later, when a patient died in the emergency room after staff used the wrong blood type during a transfusion. The error was so severe that “The fatal mistake followed a pattern of blood labeling errors at St. Luke’s, according to a report from the Medicare agency made public in February.”