More details are now emerging of the serious deficiencies in patient care that were identified at the University of Texas MD Anderson Cancer Center, Houston, last summer during an inspection by the Centers for Medicare & Medicaid Services (CMS).
That inspection, carried out in August 2019, identified deficiencies in nine of the 23 areas surveyed, including nursing, pharmacy, outpatient services, food services, patient rights, infection control, and surgical services. Some of these deficiencies posed an “immediate jeopardy to the health and safety of all patients,” the CMS stated in its report.
The CMS report also highlighted two patient deaths that appear to be related to the deficiencies. One patient death appears to be related to the failure to notify the physician of patient changes; the other was the result of a medication error.
This comes on top of the two investigations of operations at MD Anderson in April and May 2019, which found deficiencies in nursing care, laboratory services, patients’ rights, quality assurance, and institutional oversight. Those investigations were prompted by the death (in December 2018) of a 23-year-old leukemia patient who received a contaminated blood product, as previously reported by Medscape Medical News.
MD Anderson announced in June 2019 a “corrective plan” that focuses on revisions of its policies, education, and training following these earlier CMS reports. One safeguard in this plan was to create a first-of-its-kind Hemovigilance Unit to provide real-time surveillance of all patients undergoing or who had recently received a blood transfusion.
In a letter sent on October 3rd to the CMS, MD Anderson President Peter Pisters, MD, said that the center had taken “swift and decisive actions” to ensure compliance, especially regarding the immediate-jeopardy violations.
More recently, in a statement released on November 4, the center said that it had “implemented changes into our clinical practice.”
“A survey to validate MD Anderson’s approved improvement plan was conducted by CMS during the week of Oct 28,” the center said in the statement. “Several steps remain, but CMS surveyors verbally shared with MD Anderson leadership that the institution has cleared all condition-level findings from the August hospital survey and its deemed status will be reinstated.”
MD Anderson has for years been ranked as the top cancer hospital in the United States. It came in first place again last year in a survey conducted by the US News and World Report for 2019 and has held the first place position for 15 of the 17 years that the survey has been conducted.
Details of the Two Deaths
Nursing staff failed to provide patient care and treatment in accordance with the facility’s policies and physician orders and/or notify medical staff of changes in the condition for all 29 patients who were reviewed.
CMS also found that the number of licensed registered nurses and other personnel was inadequate for providing care sufficient to meet the needs of patients. The lack of staffing, the report noted, “resulted in inability to provide care that was ordered for the patient.”
One of the patient deaths noted in the report appears to be related to the failure to notify the physician of patient changes. A chart review revealed that the physician had entered vital sign parameters that were to be maintained and had asked to be notified if there was a change.
However, in six instances, the nurse failed to notify the physician of vital signs that were outside the set parameters. It is not clear whether the failure to notify the physician was the cause of death, inasmuch as the report only notes that the patient became unresponsive during the shift in question and died several days later.
The second death was the result of medication error, the report noted. This case involved a 54-year-old brain cancer patient who had an “untoward reaction” to an “overdosage” of bupivacaine and lidocaine that were injected into her scalp prior to a scheduled radiation treatment.