Saint Raphael Fined For Drug Overdoses
For the second time in less than two years, the Hospital of Saint Raphael has been cited by the state for drug overdoses that killed a 21-year-old patient and landed another in intensive care.
Reckless drug dosing and monitoring have thrust Saint Raphael under the scrutinous eye of the state Department of Public Health, resulting in two fines, additional state oversight, and a number of costly practice changes.
The cost of improvements will likely trump the state’s $30,000 fine, said DPH spokesman William Gerrish.
“It’s the strategy on the department’s part,” Gerrish added, “because we are in essence focusing their resources on efforts that are going to improve care.”
The hospital’s problems with the DPH began in November 2005 when a 21-year-old patient died as a result of a hospital-administered overdose of potassium chloride. The hospital was fined $18,000, and DPH called for changes in hospital systems and policies as well as extensive staff education and retraining to prevent future fatalities.
Now, the 511-bed community teaching hospital is being fined an additional $12,000, again faulted for shoddy medication monitoring procedures, among other issues. This time, two patients were given non-fatal hospital-administered overdoses.
Lack Of Compliance
“When we take action against a facility, we go back in to see if they’re doing what they’re supposed to be doing,” Gerrish said.
The latest DPH order details the experience of one patient admitted to the hospital, suffering from alcohol withdrawal. The more agitated the patient became, a higher dosage of the sedative Ativan was given. The overdose landed the patient in an intensive care unit, “intubated for airway protection.”
The patient was discharged six days after being admitted, according to a DPH report.
Another patient suffering from a serious complication of type 1 diabetes received an overdose of the sedative Fentanyl, from which he “had no adverse effects,” the DPH report states.
Although medication monitoring issues have persisted, the DPH’s recent investigation revealed additional problems at the hospital. According to the DPH report, hospital staff have been slacking when it comes to monitoring patients’ bed sores.
In one case, a patient waited more than two weeks for a visit from the hospital’s wound care specialist for treatment for bed sores. And after that visit, no further wound check-ups are documented—although the specialist claims to have seen the patient frequently, but had just not jotted those visits down.
The DPH’s investigation reveals several violations of the hospital’s own wound policy. Bed sores were not consistently measured and monitored, and some days would pass with no wound checks at all.
Hospital officials voluntarily signed the DPH consent order and they have been working to improve operations since the first order was issued in 2006.
Improvements On Course
“Saint Raphael’s take these reviews very seriously as they help the hospital further improve the excellent, safe care provided to thousands of patients each year,” the hospital said in a statement. “Saint Raphael’s goal is to always be in compliance with or exceed the many hundreds of standards that these [regulatory] groups have.”
The modified consent order the hospital signed on Jan. 4 includes some of the same requirements issued in the first, 2006 consent order, as well as some costly new demands.
“Many of the actions called for in the newly signed consent agreement are part of corrective action plans already implemented by Saint Raphael’s and approved by the state last year,” hospital officials said in a written statement. “These action plans include policy revisions, practice modifications, education and the development of audit mechanisms.”
The DPH is also asking the hospital to review and revise policies relating to physician orders for intravenous medication administration, parameters for pain control and intravenous drip medication administration and patient assessments to determine medication effect and possible negative outcomes.
More expensive requirements included in the order call for the appointment of a pharmacist, who will participate in staff rounds and help supervise medication issues, and an independent wound care nurse consultant, who will examine the hospital’s wound care policy and report findings to the state.
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