State says rules broken at Saint Mary's, Waterbury, Hungerford
BY CARRIE MACMILLAN | REPUBLICAN-AMERICAN Related links
Waterbury Hospital consent order
Charlotte Hungerford consent order
St. Mary's consent order
In the past four months, three area hospitals have been written up for violations ranging from expired medications to a seven-inch surgical swab left inside a patient for eight days.
The reports, called "health care facility regulatory action orders" — or "consent orders" — were filed by the Connecticut Department of Public Health and included Waterbury Hospital, Saint Mary's Hospital and Torrington's Charlotte Hungerford Hospital.
Many of the violations were cited by DPH investigators who made unannounced visits to the hospitals. The consent order for Waterbury Hospital was published Feb. 26.
Among the more egregious citations was one from June 2009 when a patient with blood clots in the lungs was admitted. That night, he had no pulse. Doctors performed CPR and a defibrillator was brought in to restart his heart. The machine did not work. Doctors tried a second machine, which also didn't work. They went back to the first machine. Five minutes had passed since the initial attempt. This time, the machine worked. But a half-hour later, the patient died.
According to the DPH report, neither of the two faulty defibrillators were, per hospital policy, reported to the clinical engineering department and removed from service. DPH investigators interviewed the involved doctors, one of whom said that the defibrillator cable on the first machine was not properly connected.
"Our physicians are very aware that if a piece of equipment does not function, it should be tagged and sent to engineering, but the staff did not believe it was an equipment malfunction," said Dr. Steven Schneider, vice president of medical affairs at Waterbury Hospital, explaining that both defibrillators later functioned normally. "But going forward, even if they don't know if it's the equipment or not, it will be sent to engineering."
DPH investigators found other machines, including defibrillators and ventilators, that were overdue for routine maintenance.
The hospital has since hired a consulting firm to evaluate and offer recommendations on the upkeep of its estimated 4,000 pieces of clinical equipment and oversee other issues. The cost of hiring such a firm is in the $400,000 range, said John Tobin, hospital president and chief executive officer.
"What's important to keep in context is that there were instances of other hospitals having equipment failures and the DPH is aware of these systemic failures," Tobin said. "We have an excellent clinical engineering department and just because a piece of equipment misses its due date for some preventive maintenance doesn't mean it isn't working. There are many pieces of equipment that are checked daily. But we take these things very seriously and we have taken some pretty extreme steps to fix these problems."
Tobin said he expects a final report of recommendations from the consulting firm, many of which already have been implemented, in the next few weeks. Other violations cited in the DPH consent order included a doctor who wore a gown, but no gloves, when he entered the room of a patient infected with Clostridium difficile — a germ that is resistant to many antibiotics. Visitors were observed in the same room without gowns and/or gloves and did not wash their hands.
To read the complete story see Saturday's Republican-American or our electronic edition at http://republicanamerican.ct.newsmemory.com.
