Hartford Hospital’s probation has been extended after state investigators uncovered more than 30 new public health code violations, including one in which a 13-inch surgical instrument was left inside a patient’s abdomen for more than two weeks following surgery.
The state Department of Public Health had placed the hospital on a one-year probation in 2008, which should have been lifted on Feb. 8.
The 867-bed hospital was cited for multiple, systemic public health code violations, some of which resulted in the deaths of four patients. The probation followed previous consent orders pertaining to health code violations in 2006 and in 2007.
According to a six-month, 87-page progress report, nearly all of items identified for improvement have been addressed by the hospital. The hospital’s probation may be lifted this month following the DPH’s final review of Hartford Hospital’s amended action plan to address numerous violations. The amended plan — with 13 changes — was submitted to the DPH on Feb. 25.
A meeting with DPH and hospital officials is scheduled for Wednesday.
The DPH licenses all state hospitals and health care providers.
Some of the additional violations occurred prior to the hospital being placed on probation or before the hospital had implemented numerous new processes. Since it was put on probation, the hospital’s top executives were replaced and a group comprised of 30 hospital staff leaders was convened and meets each day to identify ways to improve patient care. The Massachusetts General Hospital Center for Performance Excellence also conducted a review of the hospital’s systems.
Among the 30 additional violations, five were defined as adverse events, one of which Hartford Hospital failed to report as required by state law.
The most common adverse events are patient falls resulting in serious disability or death, hospital-acquired bed sores, perforations during laparoscopic or endoscopic procedures, and the retention of foreign objects in patients after surgery.
According to DPH documents, one of the adverse events pertained to a patient who had been discharged from the hospital four days after abdominal surgery in January. The patient returned to the hospital emergency room a few days following his discharge, complaining of extreme stomach and back pain. A CT scan revealed that a 2-inch by 13-inch malleable ribbon retractor — a surgical instrument — had been left inside the patient, undetected by medical staff for more more 15 days following the surgery. The instrument was removed on Feb. 3.
The additional violations were discovered by investigators on unannounced visits to Hartford Hospital, some as recent as March 12. Those violations include the hospital’s failure to report a hospital-acquired bed sore that worsened considerably following the patient’s admission. The sore eventually required a surgical procedure.
In an April 15 DPH letter to Hartford Hospital, additional violations were identified including the hospital’s failure to ensure the implementation and monitoring of a catheter inserted in the body for fever management. The catheter became stuck during removal, and a chest X-ray indicated that the catheter was in the right atrium of the patient’s heart. The catheter had to be surgically removed.
In another violation, the hospital was cited for failing to properly assess a patient’s mental status after falling. Although the proper protocols were in place for the patient, who was identified as a fall risk, the patient was discovered sitting on the floor in the doorway of his room. Upon being discovered by staff, it was noted that the patient had a bump on the back of the head, was slightly nauseous and complained of a headache. The patient was helped back to his bed. However, within hours, the patient’s condition significantly deteriorated with a change in mental status and respiratory distress, requiring intubation. The patient was eventually transferred to the hospital’s intensive care unit.
Investigators also found that the hospital failed to comprehensively document its monitoring of a patient before and after she delivered a baby. Thirty minutes following the delivery, the patient experienced a cardiac event that required multiple cardiac medications and a response by the hospital’s code team. The patient was transferred to the hospital’s intensive care unit, but the patient’s post-partum assessment status was not completely documented or assessed for more than five hours later.
Hartford Hospital spokeswoman Lee Monroe said that there have been significant improvements implemented at the hospital over the past year. In a written statement, Monroe stated, “Hartford Hospital is passionately engaged a process designed to make us the leader in patient quality and safety in the United States. Our goal is nothing less than setting national benchmarks that will bring other hospitals to our doors to learn how we do it.”
During the past year, hospital staff members have been encouraged to report areas that would improve safety care, and weekly newsletters communicate the improvements, she said.
William Gerrish, DPH spokesman, agreed that the hospital has made significant improvements.
“We feel the hospital has made considerable progress since the consent order. We have observed that the hospital has committed considerable resources to improve the quality.”
