HJBR Jul/Aug 2019

Healthcare Journal of baton rouge I  JUL / AUG 2019 23 Serious Problems The government report details a litany of problems at St. Luke’s and some of its out- patient treatment facilities. In one instance, regulators noted that a cart of medical equipment had been removed from the room of a patient with a rare flesh-eating bacteria infection, with no evidence that the cart had been disinfected and no documentation of where the cart had been taken. Infections can spread if care- givers touch a cart that carries bacteria and then come in contact with another patient. Later, an inspector observed a nurse touching a contaminated dialysis machine without gloves. When confronted, the nurse replied, “I thought because we clean it really good we do not wear gloves.” In 2018, St. Luke’s recorded worse-than- average infection rates in several areas, according to the report. When an inspec- tor asked an administrator why the hospital wasn’t tracking staff compliance with sev- eral prevention protocols, the director said it “was because of lack of resources”in infec- tion control. Hospital administrators didn’t have ade- quate follow-up processes in place to ensure staff continued to learn from serious mis- takes, regulators wrote, as was the case in 2018 after surgical objects — a sponge, a surgical towel and a cervical instrument — were mistakenly left inside three different patients during a three-month span. Medical experts consider accidentally leaving an instrument or sponge inside a patient during surgery a “never event,” meaning the error is so egregious that it should never happen. Regulators found that some nurses weren’t following hospital policy for the safe administration of medications, includ- ing one who gave an additional dose of anti-psychotropic drugs to calm a patient who’d been yelling — without first consult- ing a doctor. In some instances observed by inspectors, nursing staff failed to take steps necessary to protect frail patients from the risk of falls. In others, staff failed to ensure patients fully understood the risks before asking them to consent to a procedure. Even the facility — a 65-year-old building at the heart of the Texas Medical Center — posed a potential danger to patients, accord- ing to the inspectors, with sewage backed up in the kitchen, malfunctioning dishwashers, moldy ceiling tiles, water leaks creating slip hazards and paint chipping from walls in operating rooms. At a 2016 groundbreaking, Baylor St. Luke’s leaders said a new hospital tower to replace its aging facility would be completed by 2019, but construction contracts were later canceled. This year, hospital leaders announced the new facility is now “sched- uled for completion in the fall of 2024.” “Hospital administrators didn’t have adequate follow-up processes in place to ensure staff continued to learn from serious mistakes, regulators wrote, as was the case in 2018 after surgical objects — a sponge, a surgical towel and a cervical instrument — were mistakenly left inside three different patients during a three-month span.” Regaining Trust In response to the findings, the hospital submitted a 129-page plan of correction, including fixes to the hospital’s kitchen equipment, and several policy, staffing and training changes aimed at correcting each of the deficiencies. Specifically, the hospital reported that it conducted training to ensure the safe use of dialysis machines, changed the process to ensure doctors track the administration of psychotropic drugs and increased oversight of all hospital departments, including die- tary services, infection control and surgery. “Many significant improvements already have been completed across the hospital,” Lawson wrote, adding, “we are confident remaining findings will be implemented in the coming weeks.” VivianHo, a health care economist at Rice University, said the hospital’s new leadership team now must work to regain the trust of the community. “I’mconcerned that this news could cause them to lose patients, and reduced patient volume means lower revenues and affects their ability to provide quality care,”Ho said. “It becomes a vicious cycle.” Ho, who’s also a professor at Baylor Col- lege of Medicine, which helps manage St. Luke’s, said she hopes hospital administra- tors succeed in turning things around. “Robust local competition leads to better care for patients,”Ho said. “We can’t afford to lose this hospital in Houston.” n