CFVMC has engaged The Greeley Company to consult on the review process. Cape Fear Valley has been working with Greeley since December to make improvements in its emergency department and the discharge documentation process. According to CFVMS, improvements include the addition of a physician in the triage area and the addition of a clinical person in the emergency department waiting room to perform reassessments on patients. (Full disclosure: The Greeley Company is a division of HCPro, as is HealthLeaders Media.)
CFVMC has faced a series of CMS surveys in recent months. The first, in October 2011, stemmed from an April 2011 incident that involved the death of a patient. According to CMS documents released to HealthLeaders Media as part of a request under the Freedom of Information Act, a 27-year-old behavioral health patient was physically restrained on the floor of his emergency department room by two contracted police officers "who were not trained in patient de-escalation or therapeutic hold techniques."
After the October survey visit, CMS notified CFVMC that it faced immediate jeopardy status in four broad categories: governing body, patient rights, quality assessment/performance improvement and nursing services. While the immediate jeopardy status put Cape Fear Valley's Medicare participation at risk, its status as a safety-net hospital made it unlikely that CMS would take that step.
At that time, the medical center developed a corrective action plan, but in a November 29 letter, CMS notified Cape Fear Valley that a follow-up survey indicated that the four original deficiencies remained. And new deficiencies in physical environment and emergency services were identified.