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April 1, 2013
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Mercy Medical Center mistake among 82 statewide now available online

A nationwide database of incidents at hospitals across the country over the past two years includes a report of a nurse at Mercy Medical Center in Roseburg who abused a demented and combative patient in 2011.

The U.S. Centers for Medicare and Medicaid recently released inspection reports for hospitals in response to requests from the Association of Health Care Journalists, which has compiled them into a searchable database available to the public.

The Statesman Journal in Salem reported that since January 2011, inspectors have found at least 82 violations during complaint investigations at Oregon hospitals. The federal agency collects reports from all hospitals that receive payments from Medicare or Medicaid. The Roseburg Veterans Affairs Medical Center is not among the hospitals from which reports were collected.

A Mercy Medical Center nurse identified only as Employee 4 wrapped the cord of an emergency call machine around the unidentified patient’s neck on May 30, 2011, while the patient was on the toilet, and told the man or woman to shut up, according to a report complied by the Centers for Medicare and Medicaid.

A certified nursing assistant who had witnessed the incident reported it to the nursing supervisor, who did not report the incident to another member of management until June 7. The nurse was suspended the following day.

Law enforcement and other state officials were not contacted as directed by policy, according to the federal hospital inspection report.

Deb Boswell, chief operations officer and chief nursing officer for Mercy, said today she took action immediately after becoming aware of the incident.

The nurse was disciplined and adult protective services was notified, she said. An educational session was also held for staff members to review hospital policy, she said.

Boswell said the nurse was fired, though she declined to say whether the nurse was dismissed because of this incident.

The hospital was surveyed following receipt of a complaint from a certified nursing assistant that she had witnessed the incident. According to the report, Patient 5 was the only patient among 10 sampled to have been abused. Federal inspectors found that the hospital failed to follow its own policies to protect the patient from further abuse by waiting a week to take action.

Boswell said she believes this was an isolated incident uncharacteristic of care provided at Mercy.

“I’ve been here off and on for 25 years and I have never seen an incident like this occur. We take our patient’s safety very seriously,” Boswell said.

Mistakes made at other hospitals ranged from the unsanitary to the dangerous, according to a story by Statesman Journal staff writer Danielle Peterson.

At St. Charles Medical Center in Bend, employees failed to notice that a cleaning machine was accidentally reprogrammed to leave out the disinfection cycle. Eighteen patients received colonoscopies with scopes that had been only rinsed with water and alcohol.

At Legacy Emanuel Medical Center in Portland, a nurse accidentally connected a nasogastric tube to oxygen rather than suction. The patient immediately went into cardiac arrest but the nurse did not tell responding physicians about the mistake. The patient was taken to surgery but died two days later of shock and multiple organ failure.

At Salem Hospital, the parents of a 14-month-old child recovering from anesthesia were told the child was “very sleepy.” In fact, the child had stopped breathing and was turning blue. A nurse told investigators that the anesthesiologist had “bagged” the child, or assisted with breathing, for 20 minutes, and that the child had required two doses of Narcon, which is ordered for oversedation, to wake up.

Curry General Hospital in Gold Beach had the most violations statewide, with 12 deficiencies found during two inspections in 2011.

Salem Hospital followed, with nine violations found during five inspections.

Three centered on patient rights, two on anesthesia, two on registered nurse supervision of nursing care, one on nursing care plan, and one on staffing and delivery of care.

“We take every one of these seriously,” Cheryl Nester Wolfe, the hospital’s chief operating officer, told the Statesman Journal. “It’s a good opportunity to examine our system and figure out where we can make improvements.”

The database is at hospitalinspections.org.

• Reporter Carisa Cegavske at 541-957-4213 or ccegavske@nrtoday.com.


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The News-Review Updated Apr 3, 2013 12:07PM Published Apr 3, 2013 04:45PM Copyright 2013 The News-Review. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.