Grady Memorial Hospital did not receive a clean bill of health following a full inspection survey of the facility, but it is no longer on life support. The Atlanta hospital has resolved serious deficiencies in patient rights and nursing services identified during an earlier survey by the Centers for Medicare & Medicaid Services, and now faces no medical care issues. However, deficiencies remain in the broad category of physical environment.
John Haupert, the new Grady CEO, was notified of the continuing deficiencies in a November 14 letter from the CMS regional office in Atlanta. According to the letter, the latest findings mean the hospital still does not meet the CMS conditions of participation and, unless the deficiencies are resolved, faces termination of its federal Medicare contract effective January 25, 2012.
The 680-bed safety net hospital has until November 24 to develop a corrective action plan (CAP) to address the remaining deficiencies.
Haupert has some experience in contending with CMS surveys. He was formerly COO of the Dallas-based Parkland Memorial Hospital. Parkland and Dallas CMS officials recently signed an agreement to permit that hospital to remain open while it works to correct deficiencies.
According to the 12-page survey report released late Tuesday by CMS, the remaining problems are mostly violations of fire codes, including blocked exits, aging sprinklers, the use of unauthorized space heaters, smoke barriers that don't meet fire resistance standards, and open electrical boxes.
In a telephone interview, Haupert told HealthLeaders Media that Grady has already resolved all issues related to the physical environment deficiency and will include that information in the CAP the hospital must file before Thanksgiving. CMS is required to perform a third survey to confirm that the problems have been fixed.
Haupert, who had been on the job less than a week when the first survey was conducted, estimates that the hospital has spent about $2 million on staffing and the building improvements necessary to correct the deficiencies identified in the first and second surveys.
The Grady Memorial inspections are related to the September death of a female patient who jumped from her 11th-floor hospital room window. The patient was not supposed to be left alone, but on the night of her death her unit was understaffed and no paid sitters were available.
Following the first survey, CMS officials said the deficiencies discovered at Grady Memorial in patient rights, nursing services, and the physical environment were so serious as to limit the hospital's "ability to render adequate care." The survey report noted that staffing issues and a lack of safety protocols contributed to the deficiencies.
Haupert says Grady has added about a dozen new patient sitters and put into place protocols to insure that the sitters follow physician orders. It has also developed documents that each sitter completes at the end of a shift before handing off a patient to another sitter or other hospital personnel. Additional personnel have also been hired for Grady's medical-surgical units.
Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
