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Hospital ‘deficiencies’ cited in man’s death

This story was published on Feb. 06, 2008 on Page A1 in all editions of the Bangor Daily News

MACHIAS – A monthlong investigation into circumstances surrounding the death of an Eastport man has concluded that a local hospital must correct a number of deficiencies in its policies and procedures.

The 73-page document, obtained Tuesday by the Bangor Daily News, comes a little more than a month after Reid Emery, 61, was released from Down East Community Hospital on the snowy evening of Jan. 1 and found dead the next day in a nearby snowbank.

The report includes a “statement of deficiencies” prepared by the Center for Medicare and Medicaid Services and a “plan of correction” offered by Down East Community Hospital.

CMS, a division of the U.S. Department of Health and Human Services, oversees health care coverage at U.S. hospitals and ensures compliance with certain federal regulations.

The statement of deficiencies prepared by the CMS regional office in Boston said that the hospital was out of compliance with Medicare conditions of participation. It specified, among other points, that the hospital failed to adequately meet the needs of the patient, that there was no evidence physicians followed hospital policy concerning discharge of patients, and no evidence that nursing staff followed policies concerning suicide precautions and discharge of patients.

The statement includes interviews with numerous hospital staff members, who were not identified by name but oversaw Emery’s care while he was a patient at DECH.

The following is a summary of that document, which was obtained from CMS through a Maine Freedom of Access request.

When Emery was admitted to the Machias hospital on Dec. 28, he had been suffering from chronic abdominal pain for several months. He also exhibited symptoms of anxiety and depression.

Before his admittance, Emery already was taking a host of medications, including Trazodone, a sedative and antidepressant, Valium, another sedative, and Fentanyl, a powerful painkiller.

An interview with one of his physicians indicated that on New Year’s Eve, Emery was “getting Demerol [another painkiller] every hour and requesting it adamantly.”

According to the statement, he also told a nurse he thought he had AIDS and at one point said he wanted to get a gun and kill himself because of the pain he was experiencing.

Interviews with a nurse and physician, however, provided conflicting reports on Emery’s suicidal behavior. The nurse indicated that the doctor was made aware of the suicidal threats, but the doctor denied that and there was no official record that Emery had made those threats.

On Jan. 1, Emery was taking the following medications: Fentanyl, Demerol, Dilaudid and Ketorolac. The side effects of that drug cocktail, according to the report, included sedation, paradoxical or obscure anxiety and clouded senses.

During the evening of Jan. 1, Emery told a nurse that he wanted to be discharged from the hospital. He even pulled out his IV tubes at one point, according to the report.

A nurse who was working the night of Jan. 1 said the patient was warned that it was snowing outside. Emery said he didn’t care. The nurse then offered to arrange a ride, but Emery said he didn’t need one because he knew someone who lived nearby.

“I was leaving when [the patient] stood and put on [his] pants,” the nurse said. “I then called the supervisor and told [the supervisor] the situation. I didn’t see the patient again.”

Emery’s physician reportedly was called and told of his patient’s wish to be released. The doctor authorized the release and told supervisors to call police if there were any problems, the report stated.

“There was no evidence that the physician spoke with the patient prior to the patient’s discharge,” the report stated.

According to an interview with the hospital’s director of quality improvement, a supervisor called her at 5:30 a.m. Jan. 2 to say that Emery could not be found anywhere.

The hospital was notified later that day when the man’s body was found buried under a pile of snow near a building adjacent to the hospital.

Based on this information, the statement of deficiencies concluded that the hospital staff “failed to follow the hospital’s written policies and meet the needs of a patient.”

Additionally, the report stated, “in spite of the patient stating [he] wanted to get a gun and kill [himself], there was no evidence that a suicide care plan had been initiated as required by the ‘suicidal precautions’ policy.”

Emery’s son, Mark Emery, a member of the Eastport Police Department, declined to comment Tuesday because his family hasn’t seen a copy of the report.

“I’m sure it will be hard to read, but we want the truth to come out,” Emery said by telephone.

Robin Popp, a hospital spokeswoman, said in an e-mail Tuesday evening that the hospital is working on a statement.

Also included in the report obtained by the Bangor Daily News was the hospital’s “plan of correction,” which DECH was required to submit under CMS’s conditions of participation for critical access hospitals.

“DECH takes its responsibilities for assuring patient safety very seriously,” Wayne Dodwell, the hospital’s president and CEO, wrote in a letter to CMS. “Even before receiving your letter, DECH was in the process of implementing aggressive measures to address the issues it had identified to improve patient safety measures.”

In that “plan of correction,” which totals about 50 pages, DECH outlined a number of different policy revisions, including policies related to discharge of patients and patients who exhibit suicidal tendencies. One revision requires in-person consultation by a physician for determination of patient decision making capacity.

The hospital also indicated that it has established a patient safety task force to ensure that its practices related to patient safety and quality of care meet applicable standards for organizational structure, staffing, provision of services and nursing services.

The task force will educate hospital staff on those standards and assure compliance, and the plan indicated that numerous education programs have been initiated since early January.

The plan of correction in its entirety will be adopted no later than Feb. 11, according to the report.

The statement of deficiencies and plan of correction are administrative findings and not legal determinations. So far, no charges or other legal action have been levied against DECH regarding the death of Reid Emery.

erussell@bangordailynews.net

664-0524

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