Deficiencies at Grady Memorial Prompt CMS Review

A complaint survey into the death of a 60-year-old patient, who jumped from her 11^th floor room at Grady Memorial Hospital, has identified serious deficiencies at the hospital that limit the hospital's "ability to render adequate care" and will require a full survey of the facility, according to the Centers for Medicare & Medicaid Services. The deficiencies also prevent Grady from "being in compliance" with the conditions of participation for the federal Medicare program.

Alston "Pete" Correll, who chairs the Grady Memorial board of directors, was notified of the hospital's deficiencies in a Sept. 28 letter from the Atlanta office of CMS. HealthLeaders Media obtained a copy of the letter and the deficiency report from CMS on Friday following a freedom of information request. Grady Memorial Hospital declined to provide documents or information related to the complaint survey.

At the time Grady Memorial was awaiting the arrival of its new CEO, John Haupert, who arrived on Oct 3. He was formerly COO of Parkland Memorial in Dallas. Parkland and Dallas CMS officials recently signed a systems improvement agreement to permit that hospital to remain open while it works to correct deficiencies that threatened its closure.

A complaint survey can originate from several sources, including patients or their families. Efforts to identify who initiated the complaint survey were unsuccessful. The complaint survey was conducted by an unidentified state survey agency.

A full survey of the 689-bed Grady Memorial will be conducted in the next few weeks, according to the CMS letter. The survey team will arrive unannounced and spend several days looking at all aspects of the hospital facility and operations. If any deficiencies are identified during the survey,  Grady Memorial will be required to submit to CMS a corrective action plan that separately addresses each deficiency..

As noted in the 52-page survey report, Grady's current deficiencies fall into three broad categories: patient rights, nursing services, and physical environment. All of the deficiencies are related to the Sept 6 patient death.

According to the report findings the patient was admitted" to receive treatment for seizures and alcohol withdrawal." On the ninth day of the patient's hospitalization physician orders "revealed the patient was to be on 1:1 monitoring." However, on Sept. 6 there were "no available sitters for the 11p.m to 7 a.m. shift." Instead, staff was going to check on the patient "as often as possible." A registered nurse noticed that the patient was missing around 1:50 p.m. and that the patient's room window was open. The RN "looked out the window and saw something on the street." Accompanied by the charge nurse, the RN "went downstairs and found the patient's body on the street."

The survey report noted these issues that contributed to the deficiencies:

• The patient's unit was understaffed during 20 of 21 shifts from Sept. 1 to Sept. 7.
• No documented evidence of the patient having a sitter in either the nursing notes or the patient's plan of care.
• No sitter observation or hand-off forms were included in the patient's records.
• No protocol for assessing the safety of patient room windows was in effect.

It also identified steps the hospital has already taken to correct the deficiencies:

• Staff has been added to the medical-surgical units.
•  Overtime has been authorized for unlicensed staff to work as sitters.
• Education and training sessions have been implemented for sitters regarding safety and compliance to sitter documentation logs
• All 566 of the hospital's operable windows have been inspected and 21 were found unlocked. Standard screws were replaced with tamper-proof screws.

The hospital's media department provided via e-mail this statement, which was dated Oct. 6: "There were some initial findings resulting from the state Department of Human Services review that occurred immediately following the September 6 incident. We are aware of those findings and are implementing corrective actions. At the same time we are preparing for a full unannounced survey by the Centers for Medicare and Medicaid, which is standard in situations like this. We were expecting CMS survey notification and received it on September 28."

How much Medicare or Medicaid funding might be at risk is unknown. A Grady spokesperson would comment only that in 2010 Medicare accounted for 32% of net patient revenue while Medicaid accounted for 40% of net patient revenue.