VIDEO: Full CMS Report Tells a Tale of More Than Just “Physical Environment” Problems at GMH


Guam – A survey report issued by the U.S. Centers for Medicare and Medicaid paints a grim and wide ranging picture of problems facing Guam Memorial Hospital that go far beyond “physical environment” problems with the hospital building itself.

In a letter to Acting GMH Administrator Rey Vega, CMS Certification Manager Rufus Arther wrote that “these deficiencies [at GMH] are of such a character as to pose immediate jeopardy to the health and safety of the agency’s patients.”

READ the letter from CMS to GMH Administrator Rey Vega

However,  GMH Administrator Vega told PNC News Wednesday afternoon that CMS’s concerns had mostly to do with the “physical environment” in which the patients are cared. The condition and threats posed by the building, not the quality of care.

“They only cited us for the ‘Life Safety Code,'” said Vega, “meaning the physical environment of the hospital.”

But the 75 page FULL report obtained by PNC News Wednesday evening details numerous problems, beyond the “physical environment.”

READ the FULL report from CMS on its May 27th Survey of GMH

Among the items cited in the FULL survey report are failure to examine the credentials of medical staff, failure to meet standards in the administration of drugs, lack of patient privacy, expired medical devices and medications, failure to ensure confidentiality of medical records.

The list, full of examples, goes on for 78 pages. The “physical environment” issues don’t begin to be raised until page 59.


1. Medical Staff Credentialing: This STANDARD is not met as evidenced by:

“Based on document review and interview, the hospital did not always examine the credentials of members for reappointment to the medical staff.”


Dr. 26

*”Review … of the credential file … revealed an evaluation checklist completed by Dr. 26 attesting that he had not had any hospital privileges suspended. Further review of the credential file however revealed that on 5/25/08, Dr. 26’s hospital privileges were suspended and then reinstated on 5/26/08.”

* “…review of radiology reports revealed that Dr. 26 had over a hundred that had no interpretation or were either unsigned or not signed timely rendering the reports preliminary instead of final.”

* “interviews with staff revealed that getting the reports signed promptly by Dr. 26 was an ongoing issue.”

2. Administration of Drugs: This STANDARD is not met as evidenced by:

“based on observation, and interview the facility failed to ensure that drugs and biological must be prepared and administered in accordance with Federal and State laws … Failure to ensure that drugs and biological are prepared .. in accordance with accepted standards of practice … could subject the patients to an increased risk for medication errors.”


Tour of the ED on 5/25/11:

* “in the ‘suture room’, a 30cc multi-dose vial of Lidocaine 1% was opened (seal removed) and some of the contents removed, and there was no date on the container indicating the date it was opened.”

* “In the medication storage room behind the main nursing station, there was an opened multi-dose vial of Humulin 70/30 in the refrigerator that had been opened. the label on the container indicated it had been opened on 4/23 and had an expiration of 5/23/11.”

* “During an interview with L25, she stated that the multi-dose medication vials should have had an expiration date, and that the the Humlin container should have been discarded after 5/23/11.”

Tour of  Operating Room Suite 1 LN 2 on 5/23/2011:

* “The nurse indicated a case had finished in Suite 1 earlier that day. The anesthesia cart was observed to have 2 five ml syringes without needles … the LN indicated that she would have expected the anesthesiologist would have discarded the medications when the case was completed.”

* “During an interview with Dr. 26 … he indicated his expectation would have been for the anesthesiologist to discard the medications in the syringes if he was finished with the operative case.”

3. Patient Rights: Personal Privacy.  This STANDARD is not met as evidenced by:

“Based on observation, the hospital did not ensure that the patient had the right to personal privacy including privacy during treatment.”


 * “care was being provided to several non-sampled patients in an ‘open’ area across from the nursing station in the main ED … where 20 chairs were assembled together in rows…Specifically, two non-sampled patients were observed receiving IV fluids and were sitting next to each other in adjacent chairs. Next to them approximately three (3) chairs over was a pediatric patient receiving an respiratory treatment. Across from these patients, a patient was being discharged to home and being given instructions that included diagnosis, aftercare instructions and other patient specific information.”

*”A non-sample patient who was in a wheelchair was observed in the public hallway outside of the nursing station. While int he middle of an interview with a physical therapy staff, a laboratory staff member approached the patient and told him that she needed a blood sample. Without waiting for acknowledgement or a response, the staff, interrupting the interview, proceeded to draw blood from Patient 32. When asked what the blood draw was for, the staff responded that it was for glucose testing.”

* LN 26 was also interviewed … and said ‘there have been several complaints about privacy and all I can do is apologize to them (patients).'”.

4. Patient Rights: Care in Safe Setting:  This STANDARD is not met as evidenced by:

 “Based on observation and interview, the hospital did not ensure that the patient had the right to receive care in a safe setting.”

EXAMPLES: [observations made on May 27, 2011]

Inspection of  the Adult Intensive Care Unit (ICU):

* “An electronic programmer had a Biomed safety check sticker dated 8/3/10 and another sticker indicating an inspection due date of 3/31/11.”

* “In one of the two crash carts, one Quick Arterial Blood Gas … had 100 units of Heparin had an expiration date of 06-2009.”

* “The suction machine in one of the crash carts did not have a safety check label from Bio-Med.”

Inspection of the emergency cart in the acute dialysis unit:

*  “A disposable kit labeled as a duel lumen catheter insertion tray (with laser-cut side slides) was observed on a table … the kit had an expiration date of February 2009.”

*  “Two red-dot electrodes with an expiration date of  March 2011 were also noted inside the cart.”

5. Patient Rights: Confidentiality of Records: This STANDARD is not met as evidenced by:

“Based on observation and interview, the hospital did not ensure the confidentiality of patients clinical records.”


* “in the trauma side of the ED … on a desk, in a viewing angle towards patients and families/visitors, was a computer screen … On the screen was the name, diagnosis, and treatment orders regarding a patient being treated in the ED. The information contained on the screen was in full view of patient families/visitors.”

* “During an interview with LN 27 … she stated that there ‘used to be a computer screen cover that was over the monitor screen that shielded view of the information on the screen … She stated that the device had been damaged and that she has been unsuccessfully “been trying to get a replacement.”