CMS report identifies patient who required dialysis due to hospital mistake

Guam Memorial Hospital (PNC file photo)

Guam – As whistleblowers uncover alleged corruption at the Guam Memorial Hospital, now the island’s only public hospital has been dealt an even bigger blow with the threat of losing CMS certification.

PNC obtained the CMS report which lists numerous citations, including one in which a patient was given medication in error resulting in dialysis treatment.

This certification is a lifeline for GMH since it is a major source of funding for the hospital. GMH CEO PeterJohn Camacho was on News Talk K57’s Morning’s with Patti on Friday.

“Well, if the Medicare funding is pulled from GMH that means that we will not be reimbursed basically for care provided to Medicare patients who come through GMH 110 and it would also impact on the ability to be reimbursed for Medicaid patients and MIP patients,” noted Camacho.

He refused to release the CMS report, saying it was unofficial, but PNC was able to obtain a copy of two separate reports—a 78-page report identifying deficiencies in patient safety and care and a 20-page report citing multiple building code violations.

The first report, right off the bat, lists a terrifying situation that CMS surveyors discovered during their April site visit: a patient was given an IV contrast by mistake resulting in the patient not requiring dialysis.

According to the report, sometime in April this year, the patient came into the emergency room with abdominal pain. The patient was diagnosed with chronic kidney disease and was ordered to have a CT scan.

Because of this pre-existing condition, an IV contrast was not recommended since it could be harmful to the patient. Instead, an oral contrast was ordered. The patient finished drinking the oral contrast and was sent to have the CT scan performed but “staff administered an IV contrast at the beginning of the procedure and immediately realized the procedure did not require IV contrast to be administered. Staff estimated he/she administered approximately 50 cubic centimeters of the IV contrast to patient in error.”

That wasn’t the only error made, according to CMS inspectors, the staff failed to file a patient safety form or a report for their grave mistake. When the risk management director was interviewed about this incident, they stated that they were unaware of the mistake.

Since the incident had just occurred about a week before the CMS inspection, surveyors were able to visit the patient who was still admitted to the hospital.

The patient told CMS that “he/she was admitted to the hospital and received his/her first dialysis treatment 6 days later. Patient stated he/she has received a second dialysis treatment a day later and was scheduled for a third dialysis treatment the following day. Patient further stated he/she had never received dialysis treatments prior to his/her admission to the hospital.”

GMH was also cited for failing to properly monitor medication carts, leaving it unlocked for hours at a time and therefore giving free access to janitors, housekeeping staff or any other passersby.

Another citation noted in the report is one we had already reported: that hospital administrators failed to ensure that some of its certified nurse midwives and certified registered nurse anesthetists were licensed to administer drugs with the DEA.

CMS also listed an incident involving the credentialing of a physician. CMS says they found at least one doctor whose background was not properly investigated, resulting in the physician’s hire under false pretenses.

It was later discovered that the hospital where the doctor came from revealed that he or she was not trained to fulfill the traditional role of a nephrologist in managing peritoneal dialysis directly.

Earlier this year, GMH was also under jeopardy of losing its Joint Commission accreditation for numerous violations. GMH administrators continue to maintain that most of their problems can be solved with more funding, but the hospital has been criticized by lawmakers and whistleblowers for failing to acknowledge that it is just as much, if not more, of a leadership issue.