Cortland Standard .net

By TYRONE L. HEPPARD
Staff Reporter
theppard@cortlandstandardnews.net
CORTLAND — Failure by staff at the Cortland Regional Medical Center to follow protocols last year led to a college student, who was considering attending medical school, intubating a patient during a medical procedure, according to the Centers for Medicare and Medicaid Services.
The action could have resulted in harm to the patient, according to a report on the incident from the federal Department of Health and Humans Services. The report outlines the hospital’s failings, saying it did not follow its own policies and procedures.
Staff reported the incident occurred on June 31, 2014, and hospital administrators and staff failed to investigate the extent of the incident or take corrective action, according to the report.
According to the “Statement of Deficiencies and Plan of Correction” report, the incident involved an observer who was, “thinking about going to medical school,” and shadowing an anesthesiologist. Hospital spokesperson Lauren Mossotti-Kline would only say that the person was a college student.
The agency report contains interviews with unidentified CRMC staff in December, who said the anesthesiologist assisted the observer who was allowed to insert a tracheal tube into the throat of a patient during the surgery.
This happened despite the hospital’s policy, stating a “job shadowing individual will never provide direct patient care and may only observe the healthcare professional’s work,” the report reads.
In addition, the report says when the incident was reported up the chain of command, the incident was not adequately investigated.
While it does not specifically name the CRMC CEO, the report quotes the CEO as saying the hospital, “dropped the ball.”
The hospital’s board of trustees hired Mark Webster as its CEO on Jan. 3, 2014. He is currently CEO and would have been CEO at the time.
Following the interviews, the state Department of Health declared the incident “Immediate Jeopardy” on Dec. 15, 2014. The term is assigned for situations where noncompliance has or is likely to cause serious injury or death to a patient, according to the Department of Health and Human Services.
That classification was removed the next day once the hospital implemented corrective procedures regarding the incident.
Remedial actions included “immediate cessation” of shadowing during surgeries. A form has also been created for observers to sign, which says they are aware hospital policy states they are not allowed to have patient contact, the report says.
In addition, hospital surgical staff were, “educated face-to-face” about these changes while other staff were notified via email to ensure everyone knows observer contact with patients is prohibited.
The anesthesiologist involved in the incident, “was counseled and a corresponding letter was placed in his/her quality improvement file at the hospital,” according to the report.
This morning, Mossotti-Kline declined to identify the anesthesiologist involved or say if he or she is still employed at the hospital, stressing in all matters of this nature, personnel details are kept confidential.
She said in a statement that the hospital recognized a fault in the system and is committed to enhancing compliance and patient safety.
“Like many hospitals, these lapses occur and we address them to the best of our ability,” she said. “The medical center is now also contracted with a team of experts specializing in the area of anesthesia.”
Mossotti-Kline also declined to say whether the patient or their family have been contacted or briefed regarding the incident.
A representative from the Centers for Medicare and Medicaid Services did not return requests for comment by press time this morning.
News of the incident comes less than a month after the hospital received a failing hospital safety grade based on data mostly from 2012 and 2013. It was the first of two biannual Hospital Safety Score evaluations conducted by the nonprofit organization the Leapfrog Group.