Bob Aller Posted: February 18, 2019 Revisions: February 24, 2019
Last week Hospital Watchdog conducted an in-depth interview with Ms. Dena Royal, a former paramedic, and respiratory therapist. Dena’s mother, Martha Wright, bled to death following a colonoscopy and a series of tragic nursing mistakes at Cass Regional Medical Center in Harrisonville (pop. 10,000) Missouri.
Dena’s vigilance and persistence as a whistleblower led to an investigation by The Centers for Medicare and Medicaid Services (CMS). Based on interviews and a review of hospital records CMS found specific events contributing to her mother’s death and issued findings in a Summary Statement of Deficiencies (posted below). Among the key problems, Martha had not been thoroughly assessed when changes in her condition occurred. In one instance, at 10:15 pm, (14 hours after the procedure), the RN failed to perform a thorough assessment that included vital signs and notifying the doctor. The CMS report also showed how after Martha’s death the hospital tried to cover up what happened.
Dena’s efforts to find out what happened were rebuffed by the hospital. When Dena requested an investigation it took 48 days after her mother’s death until the nurse caring for her mother was interviewed.
We’ve divided this report into two parts. Part 1, posted today, provides an introduction and brief overview for the case. Part 2, to be posted later, will drill down into much more detail.
Lack of Proper Nursing Care After Surgical Error
Martha Wright was pronounced dead at 5:14 am on August 3, 2018. About 21 hours earlier she had a routine colonoscopy at Cass Regional in Missouri.
The colonoscopy for Dena’s mother commenced at 7:50 am on August 2, 2018. Completed in fifteen minutes at 8:05 am, the procedure was seemingly uneventful.
The general surgeon who performed the procedure, Michael Kohlman, said: “colon looked great and no f/u needed for ten years.” There wasn’t a single polyp. But a CT scan performed the next day, (when it was too late), showed damage to her spleen from the procedure. After Martha’s death, in a phone conversation with Dena, Dr. Kohlman acknowledged possible spleen damage during the procedure.
Martha had stayed in the hospital overnight. The hospital’s policy required that following a colonoscopy a patient had to have someone stay with them for 24 hours after the procedure. (Martha did not have anyone to stay with her at home so she stayed at the hospital.)
After being rebuffed by the hospital, Dena filed a complaint with the Missouri Department of Health and Senior Services. Acting on behalf of CMS, state investigators arrived unannounced at Cass Regional on November 27, 2018. They spent 4 days at the hospital interviewing staff and examining documents.
Statement of Deficiencies Issued To Cass Regional
After a review of the information gathered from the investigation, CMS ruled that the hospital staff had not met professional standards of care related to Martha’s care. CMS placed the hospital on an Immediate Jeopardy status.
The surgeon who performed the procedure, Dr. Kohlman, had not been called when he should have been called. At various times when Martha described her pain, she was told she needed to pass gas. But passing gas wasn’t the problem. Internal bleeding was the problem. Martha suffered from wheezing, hypoactive bowel sounds, left shoulder pain, she became pale, garbled her speech, held the left side of her forehead. She had nausea and was unable to take deep breaths. She was restless, grabbing at her chest and left upper quadrant.
Severe abdominal pain following colonoscopy, especially within 24 hours, warrants a high level of suspicion. In particular, the left upper quadrant pain and left shoulder pain that occurred here are specific signs of possible injury to the spleen. The nurse caring for Martha should have recognized these signs as serious. Injury to the spleen is a known risk from a colonoscopy.
Read the CMS Summary Statement of Deficiencies & Plan of Correction.
Martha eventually displayed agonal breathing (irregular breathing that occurs at the end of life). She was also non-responsive to sternal rubs. Finally, a code blue was called at 4:55 am. Heartbeat or breathing could not be restored. It was simply too late.
Hospital Attempted Cover Up
The record of events and documents reveal that the hospital then tried to cover up what happened. These actions involved violating applicable laws, regulations and a written agreement with CMS.
Physician Did Not Contact Medical Examiner
Missouri Statute 58.720 requires that the medical examiner should be immediately notified when someone dies in an unusual or suspicious manner. Bleeding to death following a colonoscopy is most certainly an unusual manner of death. A Cass Regional doctor should have notified the medical examiner of the circumstances of the death. If the call had been made, the Medical Examiner could have determined the precise nature of Martha Wright’s death.
Physician Appeared To Falsify Death Certificate
Six days later, on August 9, 2018, Cass physician Deidra Charles completed and signed a death certificate, listing Martha Wright’s cause of death as “natural.” Most certainly, this was not a natural death.
Line A of the death certificate stated in handwriting that the immediate cause of death was “Intraabdominal Hemorrhage.” However, the printed instructions on the Cass County, Missouri form required additional conditions leading to the cause. Dr. Charles omitted the additional information required by Missouri statute.
The instructions read: Sequentially, list condition if any, leading to the cause listed on line a. Enter the underlying cause (disease or injury) that initiated the events that resulted in death. Material omission constitutes falsification.
Any physician who completes a death certificate is responsible for knowledge of the state statutes regarding medical certification of causes of death.
Board of Trustees Legally Responsible
According to its website, the hospital is owned and operated by Cass County, Missouri, and is governed by a five-member Board of Trustees elected by county voters. This hospital is a county government hospital, commonly referred to as a “district” hospital. The Board of Trustees has ultimate legal responsibility for events that happen in this hospital. It appears that Board oversight was lacking by allowing unlawful conduct and violations of Conditions of Participation with CMS.
Plan of Correction
After CMS issued its State of Deficiencies, Cass hospital responded, preparing and agreeing to a Plan of Correction. CMS designated the CEO, Chris Lang, as the responsible party.
We know something about the hospital. What about the patient?
Memories Of Mom
Dena shared some of her memories.
My mom shared her love of art and culture in our upbringing. Sundays were free at the Nelson-Atkins Art Museum in Kansas City, Missouri and she took us there often to soak up the exhibits. Every year we went to the symphony. She was known in our community for her green thumb. When she planted, flowers sprouted. She loved the birds in our neighborhood, especially hummingbirds.
I live in the state of Washington and in recent years Mom has lived independently in an apartment near my sister in Pleasant Hill, Missouri. For a long time, Mom had no significant health issues. She took no medication. Her blood pressure was normal. Though she didn’t like going to the doctor, she didn’t have much need to see a doctor. Her physical health was blessed. Mentally, she was sharp as a tack and she could recall nearly everything that happened in our lives, including all the facts about our family history.
In the months leading up to the colonoscopy, she had been feeling tired, with some weight loss and signs of possible anemia. When she saw a doctor, a colonoscopy was recommended.
CMS Identified Marth’s Death As A Sentinel Event
Martha Wright was in relatively good health when she went in for a routine colonoscopy. The treating physician and other medical staff must have recognized what happened. They were legally required by CMS to designate this “unanticipated event” as a “sentinel” event. However, the hospital did not identify Martha’s tragic death as a sentinel event.
Sentinel Event Is A Common Hospital Term
A sentinel event is defined by the Joint Commission as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness. Martha’s death perfectly fit the definition. When a sentinel event occurs, there are various required steps that must be taken.
CMS views a sentinel event as significant and requires an immediate investigation of the event and identification of the root causes of the problem, referred to as a root cause analysis or RCA. Once the problem is well understood, the hospital should promptly update policies and procedures and implement an educational program to bring staff up to date.
The reasoning is simple. If a hospital doesn’t correct conditions that led to an incident, it could easily be repeated. In this instance, Cass Regional blithely moved on and performed 348 more colonoscopies over a four months period, without taking preventive steps so that another tragic event like this one would not happen.
CMS found “these failures had the potential to place all patients in the facility at risk for their health and safety.”
The hospital management had temporarily placed CMS support in jeopardy.
Hopefully, the plan of correction implemented at Cass Regional has benefited the staff and the likelihood of another similar event had been significantly reduced.
In Part 2 of this post Hospital Watchdog will drill down and examine in more detail what happened in this case.
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