St. Michael fixes CMS compliance following investigation

Editor’s note: A CMS spokesperson clarified May 17 that the legal name of the hospital still is Harrison Memorial Hospital as the facility has not changed its name officially with CMS. All investigative documents obtained by Kitsap Daily News contain the name Harrison Memorial Hospital. The organization has requested the changing of the name to St. Michael Medical Center.

St. Michael Medical Center in Silverdale is back in substantial compliance with the Centers for Medicare and Medicaid Services after months of failure, nearly resulting in termination actions with the hospital.

The damage may already be done, however, as a Medicare Complaint Investigation conducted by the state Department of Health found Kitsap’s sole major hospital to be out of compliance with participation conditions that led to improper treatment of patients, including a reported death, and a lack of emergency preparedness that contributed to the severity of last fall’s cyber attack.

Documents obtained from CMS show investigators made visits to the hospital in 2022 from Oct. 18 to Nov. 3 and again on Nov. 9-10. A letter dated Dec. 5 informed the hospital it was out of compliance and risked termination of the Medicare program on March 5 of this year if “deficiencies have not been corrected.”

Investigators in a follow-up visit from Feb. 6-8 this year again found the hospital in violation. It was not until April 25 that St Michael was found to be in substantial compliance, another letter from CMS to the hospital says.

Staffing shortages and timely service issues are noted throughout, with investigators noting a particular set of cases in which “the hospital failed to define and ensure a standardized process to provide adequate personnel and timely assessments and reassessments to meet the needs of 3 of 3 patients presenting for emergency care.”

Wait times for physician evaluation in the emergency department in these cases spanned for hours. Investigators documented that one man presenting stroke-like symptoms arrived from an urgent care facility to the hospital on Sep. 21. A triage nurse performed a rapid exam, which was determined to be negative. The man was asked to wait in the lobby and despite being assigned an ESI of 2 (emergent), he was not given a reassessment for eight-and-a-half hours. Time stamps indicate his arrival at 10:20 p.m. and his reassessment at 6:51 the next morning.

An interview with the patient’s triage nurse indicated a full lobby of patients, and the nurse reported there was no time for reassessment. Investigators indicated the staffing levels and number of patients left just 12 nurses to care for 72 patients, a ratio of one RN for every six patients.

Similar conditions noted by investigators may have led to the death of an 81-year-old man in one case, documents say. The man arrived at 3:07 p.m. Sep. 26. Again, an ESI of 2 was assigned, but the man was physically evaluated almost five hours after arrival. It was determined at 10:25 p.m. the man had a blood clot in a crucial lung area.

The man was transferred to the Interventional Radiology suite, but in the middle of an attempt to remove the blood clot, the man became unresponsive. The patient “was intermittently unresponsive and resuscitated multiple times between 1:00 AM and 3:00 AM, when resuscitation efforts ceased due to medical futility,” the document states.

The interim emergency department manager said, “persons triaged as ESI 2 are emergent and should begin receiving evaluation and treatment rapidly.” Interviews with other staff indicated that earlier action may have saved the patient’s life.

Once again, staffing shortages appear to have played a major role as a census revealed a ratio of one RN for every eight patients or a total of 14 nurses to care for 117 patients.

Investigators also noted at least three instances where filed grievances, all regarding delays in ED delays, were given acknowledgment of receipt but were not responded to in a timely fashion as required. They wrote for all three, “Review on 10/31/22 showed no evidence of further action and no evidence that the Patient Advocate sent a written letter to the patient notifying them of the need to extend the resolution timeframe from 7 business days to up to 30 business days.”

Investigators said in four cases the type of restraint used was not noted. The interim ED manager said that electronic medical records did not have the capacity for the information.

Additionally, investigators found the hospital to be ill-prepared for emergencies, referencing the cyber attack that left staff without access to online systems and caused patient data to be exposed. They said training standards did not properly prepare staff for a downtime event, a time when computers were not available, when it came specifically to cyber attacks. Several staff reported that they had received some form of downtime training but had not received cyber attack training.