Two patient deaths led to threat to cut off funding for Wilson hospital, records show

A threat by federal regulators to cancel Medicare funding for Wilson Medical Center over serious health and safety problems came after the deaths of two hospital patients, a detailed report from state inspectors shows.

The 45-page report, obtained by The News & Observer this week, says a survey team from the N.C. Department of Health and Human Services identified “immediate jeopardy” to patients’ health and safety stemming from three separate events in early 2022. Wilson Medical Center leaders submitted a plan to correct problems identified in the report last week and are awaiting a response from the federal Centers for Medicare and Medicaid Services.

Wilson Medical Center spokesperson Melanie Raynor declined an interview request to discuss the report, telling The N&O that patient privacy laws prevented the hospital from speaking about “any situation involving current or former patients.”

“Our plan of correction has been submitted and accepted by CMS,” Raynor said. “It would be premature to provide any additional information until the follow-up survey takes place in the next few weeks.”

Federal officials warned late last month that they would terminate Medicare payments to the hospital on July 17 if staff fails to fix problems there. Patient safety experts say that outcome is unlikely as the hospital works with regulators to bring the facility into compliance.

Two of the three events cited in the report involved the deaths of patients admitted to the hospital in the early months of 2022, one who died after a fall and sedation at the facility and another who died shortly after his heart monitor was disconnected. The third incident involved a suicidal patient who locked himself in an emergency room lobby bathroom and threatened to overdose on medication that regulators say the hospital should have confiscated.

Hospital staff, the report said, “failed to ensure a safe environment for the delivery of care” to patients, failed to monitor and immediately respond to a patient’s change in condition and “neglected to supervise and perform a contraband search” for a suicidal patient waiting on treatment.

The hospital’s leadership was notified May 19 that surveyors had classified the incidents as “immediate jeopardy” cases, the least common and most serious type of deficiency that carries the most severe regulatory sanctions.

“Based on the lack of immediate corrective actions implemented by hospital staff, the Immediate Jeopardy cases were determined to be ongoing,” the report said.

‘Immediate jeopardy’ tied to two patient deaths

In January, the report said, a 70-year-old male patient was admitted to the hospital complaining of shortness of breath. Following a COVID-19 diagnosis, a doctor ordered staff to check his vital signs every four hours.

But days after he was admitted, the patient fell down in his room, and nursing staff found him on the floor with a cut to the back of the head. After a CT scan, a doctor ordered neurological checks every four hours.

The next day, nurses noted the man had “been more confused, agitated, disoriented,” and kept trying to get out of bed, a condition they noted “has drastically changed” since earlier that week. A doctor ordered him to be sedated to keep him in bed.

The last documented check of the patient was at 8 p.m. that day, when nurses recorded his blood pressure at 202/80, an elevated level surveyors said wasn’t reported to the doctor.

The man was found unresponsive seven hours later and declared dead early on Jan. 23.

Another patient, admitted in late March, underwent a procedure to remove fluid or air from around his lungs, the report said. A doctor put the 60-year-old on a continuous heart monitoring device.

But a few days later, a technician discovered that the patient’s monitor leads were disconnected and alerted a nurse, who did not immediately fix the problem. About 10 minutes later, another technician found the man unresponsive, and hospital staff started CPR.

They weren’t able to resuscitate him.

Wilson Medical Center failed to log either death as an adverse event, according to the report. The hospital also failed to report the death of the sedated man to the Centers for Medicare and Medicaid Services, which requires facilities to report deaths associated with seclusion or restraint — even “chemical restraints” like sedation.

The report also noted serious issues with the treatment of a third patient, a 41-year-old man who showed up in the emergency room in April in the midst of a mental health crisis.

The department had no available rooms.

So after determining the patient was at high risk for suicide, the report said, hospital staff left the man in the lobby to wait with his belongings — including medication he was thinking of using to intentionally overdose. Hospital staff found him two hours later locked in the lobby bathroom, where he told a mobile crisis unit that he “got his pills back and was going to take them all,” according to the report.

Although security was able to open the door and the man eventually got a hospital bed, regulators said staff failed to find and remove his medication after determining he was a suicide risk.

The three cases resulted in a list of regulatory violations involving patient rights, quality assessment and nursing services. The report also criticized the hospital’s governing body for failed oversight related to the incidents.

‘We recognize there is work to do’

In its corrective action plan, submitted to federal regulators June 28, the hospital said its staff “has taken effective measures” to fix the issues identified during the survey. Those measures included an “education blitz” for nursing staff, revised documentation policies and more audits of patient safety.

In a letter to the community this week, Wilson Medical Center CEO Mark Holyoak and Board Chair Janice Walston acknowledged that the survey “identified a few areas that required our attention and corrective action.”

“We take every evaluation seriously; however, we do not believe the results of a single survey reflect the total quality of care offered at Wilson Medical Center,” the letter read. “That said, we recognize there is work to do and have used this information to implement several initiatives aimed directly at enhancing patient safety and quality.”

Details of the letter were first reported Monday in The Wilson Times.

Walston did not return a call or email seeking comment Thursday.

Wilson County Commissioner Chris Hill, chair of the Healthcare Foundation of Wilson, which owns 20% of the medical center, said that although the hospital’s leadership briefed his board on the survey’s findings and the hospital’s response, he had not seen a copy as of Thursday afternoon.

“We’re all very concerned with the recent survey,” Hill said. “We do feel like they’re being responsive and have implemented a plan of correction and that quality of patient care is being provided and will continue to be provided.”

The other 80% of the hospital is owned by Duke LifePoint, a joint venture between LifePoint Health, based in Tennessee, and Duke Health. The collaboration, according to the hospital’s website, combines Duke’s “unparalleled expertise in clinical excellence, quality and patient safety” with LifePoint’s “financial resources and extensive operational experience.”

“In Duke’s consultative role, we reviewed Wilson Medical Center’s proposed action plans and provided guidance to ensure they met the needs to correct the CMS-identified deficiencies,” a statement from Duke Health, provided by spokesperson Sarah Avery, said.

Located about an hour east of Raleigh, the 294-bed facility currently has one star on Medicare’s quality rating site — one of only three one-star hospitals in North Carolina out of the 91 rated by Centers for Medicare and Medicaid Services,.

Loss of Medicare contract unlikely

CMS, the federal agency that provided the full report in response to a Freedom of Information Act request from the N&O, is now reviewing the hospital’s corrective action plan. State health regulators will then follow up with another unannounced survey at the facility.

“If compliance is achieved, the hospital is determined to be in compliance with the Medicare Conditions of Participation,” Elaine Kanellis, a spokesperson for CMS, said in an email Thursday. “In the most egregious cases, the provider may be terminated from the Medicare program and patients may be relocated to other facilities of their choice.”

But that outcome isn’t likely, says Dr. Joseph F. Antognini, a California anesthesiologist who’s worked both in hospital administration and as a surveyor for the Joint Commission, a nonprofit healthcare accreditation agency.

Antognini authored a 2021 study in the Journal of Patient Safety showing immediate jeopardy designations like the one at Wilson Medical Center are relatively uncommon. Out of more than 30,000 deficiencies CMS identified at facilities across the country from 2007 to 2017, less than 3% were classified as immediate jeopardy.

In an interview with The N&O this week, Antognini said most hospitals respond quickly when such complaints are identified by state and federal regulators, given the consequences of losing Medicare funding.

“The (immediate jeopardy designation) is a bit of a cudgel in that it forces a hospital to take this seriously and change their process,” said Antognini, who said he’s participated in upward of 90 hospital surveys in his work with the Joint Commission.

After reviewing the Wilson Medical Center report at The N&O’s request, he agreed that an immediate jeopardy designation was warranted. Although many hospitals might see similar isolated incidents, he said, the circumstances of all three cases together likely forced regulators’ hands.

“If this pattern were to continue, more people might die,” Antognini said.

But he said the hospital’s plan to fix these issues also seemed appropriate. It will likely earn federal approval — even though he said the facility faces the possibility of more regulatory scrutiny.

Ultimately, Antognini said, the survey process is designed to improve the care at hospitals like Wilson Medical Center.

Even so, he said regulatory actions like these underscore the need for patients to be mindful about their health care options.

“Many hospitals have similar events, and it’s important for patients to be proactive and help manage their own care.”