Calhoun Liberty Hospital in Florida was deficient when it came to patient care, emergency services and in a number of other areas when a woman died shortly after being removed from the facility by police last year, the state's Agency for Health Care Administration said in a final report (PDF) Thursday.
Agency Secretary Elizabeth Dudek called the deficiencies found at the hospital “so egregious” that the hospital will be fined and required to submit a plan of correction by Feb. 19. She said in a statement that if the hospital doesn't correct the 10 deficiencies identified in the report by March 1, it will be suspended from the Medicaid program.
Sandi Poreda, a spokesperson for Calhoun Liberty Hospital, said the 25-bed facility in Blountstown is already in the process of making the improvements.
"Our hospital has been extremely proactive about making improvements to the health care we provide to Calhoun and Liberty residents, and we are committed to meeting the deadlines put forward by the Agency for Health Care Administration," said Ruth Attaway, the hospital's CEO, in a statement. "The care we provide our residents is critical; we will not lose sight of that priority."
The report and accompanying investigation followed the death of patient Barbara Dawson in December. The agency reviewed 24 emergency room visits and found deficiencies with two, including Dawson's.
Dawson was released by doctors, but she refused to leave the hospital, saying she still felt unwell, according to the report. A police officer escorted Dawson to his patrol car, and she collapsed as she got into the police car, after saying she was having trouble breathing. Dawson was taken back to the hospital and given CPR, but she died shortly after that because of a blood clot in her lung.
Dawson's death grabbed headlines across the country and sparked outrage from the NAACP and others. Attempts to reach the law firm representing Dawson's family were not immediately successful Friday afternoon.
According to the agency's report, the hospital showed deficiencies in patient rights and care; emergency care; nursing standards of practice and policy; analysis of patient grievances; and CEO regulatory responsibility, among other things.
The report, which was heavily redacted, details the events that preceded Dawson's death.
Among the hospital's failures, it didn't perform a medical screening exam assessment of one of Dawson's main complaints before discharging her. Dawson complained of shortness of breath numerous times while in the emergency department, but was discharged without the complaint being documented, evaluated or treated, according to the report. Nursing staff also failed to notify a doctor and conduct an assessment when Dawson complained of a problem.
Poreda said the hospital doesn't dispute the facts in the report, but is concerned about the “narrative related to some of these deficiencies.”
“We're trying to make sure community does not lose faith in the hospital and at the same time we're in the process of trying to implement the changes that were already begun,” Poreda said.
According to the agency, the hospital, as part of its plan of correction, must hire a consultant who is a physician certified in emergency medicine who can train all the hospital's licensed staff. The hospital must also conduct a semi-annual audit of emergency department records to include assessment of compliance with requirements.
The agency plans to conduct a follow-up survey in the future to make sure the hospital has corrected the deficiencies.
Last month, the hospital placed three people who were directly involved in Dawson's care to non-patient care positions or on unpaid administrative leave. One has since resigned, one remains on unpaid administrative leave and one is working in a part-time capacity with materials management.
The hospital has also since hired a nationally certified emergency nurse to manage the emergency department; a licensed risk manager; and a new chief nursing officer.