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CRMC Faulted, Issues To Be Resolved

By Jeanne Sager
HARRIS — September 29, 2006 — The firm stepping in to turn around Catskill Regional Medical Center will have its work cut out for it.
Just as the New York State Department of Health released the findings from an investigation spurred by complaints from Crystal Run Healthcare regarding quality of care at the CRMC, the hospital’s board of trustees announced a Navigant Consulting of Chicago, Ill. is coming in.
According to Acting CEO Larry Cafasso, the Illinois firm will arrive in Harris on Tuesday.
The consultants will be greeted by Richard Baum, president of the board of trustees who has taken a temporary leave of absence to act as a liaison between the hospital’s administration and Navigant.
In the interim, former chair Joyce Salimeno will take the helm of the board.
Cafasso said the Department of Health (DOH) report will be included in information provided to Navigant, but he stressed that many of the issues have already been resolved.
DOH received a total of 29 complaints on 26 different patients – complaints Cafasso said were all made on May 24, all by Dr. Hal Teitelbaum, head of Crystal Run Healthcare.
DOH determined nine complaints deserved further review.
Of those nine, five were discarded because, there was “insufficient information to substantiate these allegations.”
Four other complaints were substantiated, and the DOH said the hospital was found to have violated portions of the State Hospital Code.
According to the DOH report, CRMC physicians “failed to prescribe sedatives and a paralytic agent according to prevailing standards of practice,” in one case.
“Physician’s orders were incomplete and lacked specific parameters to evaluate and adjust medication amount and frequency for medications ordered in three of three records reviewed,” the report states.
In several cases, the nurse was found to have administered the doses – determining the amount and frequence of the medications without prescribed parameters.
“This is not within the scope of nursing practice,” according to DOH regulations.
According to Cafasso, policy and procedures have been adjusted by the hospital to see that this situation is not repeated.
“If an order is given like that, it shouldn’t have been accepted by the pharmacy,” he said. “The doctor shouldn’t have written it that way, the nurse shouldn’t have administered it.”
A patient admitted for acute chest pain requested his or her own cardiologist be called in for a consultation.
The consult was done instead by a physician unfamiliar with the patient’s history even though the patient’s history form showed the name of his or her private cardiologist.
The name of that private cardiologist was listed on the emergency services record and the acknowledgement of patients rights form, and was on call at the time.
According to hospital by-laws, a consultation is required when an attending physician is not credentialed in the area of the patient’s problem.
The consulting physician is to be chosen from the on call roster or with the consultant the patient requests.
Another patient, admitted for respiratory failure, did not receive a V/Q scan (a diagnostic test for pulmonary embolism) until three days after the x-ray was ordered by the physician.
According to DOH, “nursing staff failed to coordinate a patient’s care needs for diagnostic testing with the radiology staff in a timely manner.”
The latter complaints both related to the maternity ward where a mother delivering a baby boy had to wait for both anesthesia and a physician to perform an emergency Cesarean section.
According to DOH, two of five obstetric patients did not receive anesthesia services in a timely manner.
In one case, a patient in active labor requested an epidural at 9:24 p.m., but it was two hours later, at 11:25 p.m. that the epidural was finally initiated.
In the other, an obstetrician performed a Cesarean under local anesthesia; no attempts to contact the anesthesiologist to secure more pain medication for the mother are documented.
That physician was also questioned by DOH for arriving 36 minutes after a determination was made that an emergency Cesarean had to be performed due to fetal distress.
According to state regulations, a physician is to arrive within 30 minutes of the determination that the emergency procedure is required.
The baby in question was delivered with an Apgar score of 3 at 1 minute (on a scale of 1 to 10, 10 being the best), but it had improved to 8 by the five-minute mark.
“The state requires you to be there within so many minutes, and they weren’t,” Cafasso said of each case. “That’s unacceptable.”
But in the latter case, Cafasso said the doctor’s decision to operate with only a local anesthetic saved the life of both the mother and her son.
Overall, Cafasso said the complaints were serious but no reason to doubt the safety of CRMC.
“I’m not downplaying these issues, but to go into any hospital and only find seven, you’d have a party,” he said.
“The good news is, there were no negative patient outcomes,” he continued.
The hospital’s performance improvement department routinely reviews these matters, he said, and they actually took seriously more issues than the DOH included in its report.
All have been addressed, he said, and the hospital will follow DOH requests to file a plan of correction.
There will not be any monetary penalties levied on the hospital, Cafasso said.
If these issues had been more serious, Cafasso said the DOH has the power to shut down a facility – but that will not be the case at CRMC.
The hospital may be subject to random visits by the DOH, Cafasso said, as they continue to monitor the situation.
And that will part of Navigant’s planning process – ridding the hospital of quality of care concerns as they retool the facility to meet the public’s needs.
Crystal Run Healthcare’s complaints and its decision to pull its healthcare providers and patients out of CRMC on May 31 was only a portion of the problem at the hospital, Cafasso said.
“The crisis that hit this hospital, by Crystal Run pulling out May 31, was only accelerated, but it would have happened anyway, maybe a year from now,” he said.
“The direction of the hospital has to be changed,” Cafasso continued. “We are going to focus on what the people of this county need.”
With an aging population and the county’s precarious position atop the AIDS incidence charts in New York State, there are obvious paths the hospital must chart.
“This isn’t rocket science,” Cafasso said. “They’ll probably come up with the same things we have.
“Maybe they’ll make it a smaller inpatient base,” he surmised.
At the moment, Cafasso sees the hospital as a “three-legged stool” with the board of trustees, the administration and the medical staff each an integral part in keeping the facility running.
All three will be a part of the turn-around, and he’s confident the board will allow the administration to carry out any plan Navigant comes up with.
As for the expense of hiring a consulting firm, Cafasso said the Dormitory Authority of the State of New York, the hospital’s largest creditor, will be footing the bill.
“They own this place!” he said.

Crystal Run CEO
Feels Vindicated

By Jeanne Sager
ROCK HILL — The State Department of Health says there are problems at Catskill Regional Medical Center – but what does the man whose been saying that since the spring have to say?
“We have been vindicated,” Crystal Run Healthcare CEO Dr. Hal Teitelbaum said yesterday.
Teitelbaum has said he staked the reputation of the private healthcare facility on the outcome of the DOH investigation at Catskill Regional Medical Center.
This week, he was happy to receive a letter from the DOH dated Sept. 25 with a statement of deficiencies at CRMC attached.
The report was redacted, with specific details that could compromise patient confidentiality removed, making it hard for Teitelbaum and his staff to determine exactly which cases studied relate to which cases he reported.
But he said the report corroborates Crystal Run’s most serious concerns – chiefly anesthesia on the obstetrics ward, the diversion of patients (one patient requested a consultation by a Crystal Run cardiologist and was instead visited by a member of the CRMC staff), and the dispensation of pharmaceuticals.
Teitelbaum said Crystal Run submitted between 25 and 30 complaints – the hospital’s acting CEO Larry Cafasso puts the number at 29.
Of those complaints, nine were pulled out for review and four were substantiated by medical records.
But those four included a number of subcases, Teitelbaum said – each piece of different complaints filed by Crystal Run.
As for those that could not be substantiated by the state, Teitelbaum said that’s a DOH problem, not the fault of Crystal Run’s reporting process.
“We don’t control the flow of information,” he explained. “The information is the medical records at the hospital.”
Incomplete records would not enable the state to find the information needed to proceed in the investigation.
“They’re not saying ‘Not guilty’ in those cases – they’re saying they don’t have enough info,” Teitelbaum noted.
The news that Cafasso has said the issues are already being addressed is another feather in Teitelbaum’s cap.
“I think this is a very different hospital than the hospital run by [recently resigned CEO] Mr. Brien, who said there were no problems,” he said.
Teitelbaum said he’s already seeing a more transparent hospital, an open hospital – something he’s long been asking for.
“This has never been about hurting the hospital… what this has been about, from the beginning, is improving the care for the people of this county,” Teitelbaum said. “I really do hope that this is the beginning of something great at Catskill Regional Medical Center.”
Teitelbaum wasn’t surprised by the state’s position – DOH has requested a plan of correction be filed by CRMC.
But he is frustrated that they didn’t act faster.
“The state is the state, it is what it is,” he said. “I don’t think the processes as they are on the state level are everything they could be.”
Some of the Crystal Run complaints were sent off in early 2006, the last few were sent to Albany in late April.
The report comes six months later – a shorter turnaround period might have enabled the changes at CRMC to happen that much sooner, he said.
But with new administration at CRMC, a consultant team coming in and Cafasso declaring changes are already in place to protect quality of care, Teitelbaum is optimistic.
“I hope we can get to a point where, very soon, we’re negotiating the return of Crystal Run to Catskill Regional,” he said.
As for Cafasso, he said there’s been enough “bad blood” in the Sullivan County healthcare field.
The hospital is just a few miles down Route 17 from Crystal Run’s Rock Hill offices.
“Someone new to Sullivan County … looking at the two… would think they’d work together,” Cafasso said. “I want to start off with a clean slate.”

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