Shady Grove Adventist Hospital was cited by Maryland health officials yesterday for a variety of errors in patient care, including the cases of an 81-year-old woman who underwent surgery on the wrong hip and a contagious tuberculosis patient who was allowed to wander hospital hallways.
The state weighed in one day after the Rockville hospital lost its top rating from a national accreditation group, following complaints from doctors and nurses there that patient care was suffering because of cutbacks in the nursing staff.
Carol Benner, the state's chief hospital inspector, said the problems listed in the new report form the basis for improvements she will require the hospital to make. Her office received more than 100 complaints about the hospital, which is a Maryland record for a single facility, and many of the allegations were found to be valid, she said.
The catalog of failures included medication errors and a chronic failure to note mistakes and incidents in hospital records.
The report recounted an episode in which a woman brought to the emergency room by ambulance after a horse fell on her was sent home without being X-rayed. The next day, her private doctor diagnosed broken ribs.
In another case, a patient who was placed in strict isolation because doctors suspected he had tuberculosis was found by a state surveyor freely strolling the hallways without a mask. Doctors later confirmed that he had TB, the report said.
"What greatly concerns us is the hospital's failure to have a quality assurance mechanism in place to adequately evaluate the problems and keep them from happening again," Benner said. "In some of these instances, they're repeat problems."
The report said that officials studied the minutes of hospital board of directors meetings going back a full year and that they "did not indicate any substantive discussion of quality issues or any oversight of the quality of care."
After a series of deaths of women in childbirth, for example, the hospital staff recommended an intense review of the cases. But the report said Shady Grove records listed the "action/recommendations" to be taken as "none."
Terry W. White, who was appointed as interim president of Shady Grove last week in a top-level management shake-up, said the state report has flaws.
"Obviously, the case summaries in the state report are not the patient charts, and we have a lot more information on each of those cases," he said. "We have some disagreements on the conclusions."
Benner this week alerted federal officials that the 263-bed hospital failed to meet conditions for receiving Medicare and Medicaid payments. She recommended that the state take over regulation of the hospital from the accreditation group until Shady Grove's deficiencies have been corrected.
If Shady Grove ultimately loses an appeal to keep its accreditation, the facility would become the only unaccredited hospital in the state and would be in danger of losing contracts with dozens of private health plans, including health maintenance organizations.
White said yesterday he is confident the hospital will win its appeal and disputed Benner's findings. Nonetheless, he said, steps are being taken to repair problems.
"To the extent that there were quality shortcomings, we are aggressively working to address those," he said.
The single death cited by the state involved Anna Belle Beier, 79, of Potomac, an intensive-care patient who was wheeled to the radiology department on Oct. 5. She was given barium to swallow so X-rays could be taken.
The test was halted when she vomited the barium. Medical personnel recommended that her throat and lungs be cleared with suction equipment. Instead, Beier was left in a hallway without attention from a nurse.
She was discovered 25 minutes later in cardiac arrest. When doctors and nurses responded to a call for help, the hospital's suctioning equipment failed to work. Twenty minutes later, she was pronounced dead.
White acknowledged Beier's death as a major failure.
"It was not handled in an optimal fashion," White said. "That was a letdown in care for the patient that this organization has agonized over a great deal."
In December, an 81-year-old woman who had broken her right hip arrived in the emergency room and was X-rayed, but the emergency physician wrote "left hip fracture" on the chart and sent her to the operating room for surgical repair, the state report said.
Although X-rays were taken during surgery too, the doctors failed to see that they were operating on the wrong hip, according to the report. The next day, the patient began complaining of pain in the right hip, and three days after that, another X-ray of her right hip showed the fracture had grown worse. She was operated on again, this time on the correct hip. The hospital "identified a language barrier by the patient's family as a main factor contributing to this error," the report said.
"These kinds of cases are serious, and the hospital is taking them seriously," White said. "The reaction has been very strong in trying to correct that kind of thing from ever happening again."
The most common problem cited by the state related to patients falling while trying to walk without assistance from the staff. All those accidents occurred when patients grew impatient after pressing the nurse-call button for help in moving about the room, typically to go to the bathroom, Benner said.
The report described cases of a 40-year-old woman who fell after knee surgery and broke her ankle, an 88-year-old man admitted for head surgery after falling at home who later fell in the hospital and suffered another head injury, and an 88-year-old woman who fell in the hospital after she was admitted after a fall in her nursing home.
"It certainly appears these are patients who should have been supervised and given assistance with walking, and they didn't get it," Benner said.
White said medication errors and patient falls occur at all hospitals and are to some extent unavoidable, but he pledged that Shady Grove would work to prevent them. "I don't know how you can correlate falls to nurse staffing," he said. "Patients can make their own decisions."
The report also cited the December case of a patient's amputated leg that was lost in a hospital laboratory, where it was sent to be tested. The limb, which was gangrenous, disappeared without a trace, Benner said.
CAPTION: Maryland officials say Shady Grove Adventist Hospital often responded to mistakes with inaction. The hospital's chief says it is "aggressively working" to solve problems.