LEWISTON — Central Maine Medical Center has so many problems — including a nursing error in October that left a patient paralyzed — that the federal government might stop paying for Medicare and Medicaid patients to be admitted there.
The problems were uncovered by federal investigators who visited in January, March and April. If the hospital does not correct its issues by June 30, it stands to lose tens of millions of dollars a year, a sizable chunk of its revenue.
CMMC leaders declined to answer questions about the situation. On Thursday, they issued a written statement that read, in part: “We take every patient complaint — and all feedback — very seriously. While some complaints were found to be unsubstantiated, (the Centers for Medicare and Medicaid Services) identified areas for improvement. We are working very closely with CMS to address those areas, and to ensure that we continue to provide safe, reliable and high-quality care.”
They added, “We expect the surveyors will be back next month to validate that CMMC has implemented those improvements, and we fully expect CMS to confirm our compliance.”
A January investigation by the Centers for Medicare and Medicaid Services found a number of problems at CMMC, including: the failure of hospital leaders to ensure that a life-changing medical error was thoroughly reviewed; the failure of hospital leaders to prevent that error from happening in the first place; the failure of the hospital to identify and address documentation disparities in that patient’s medical record; and multiple failures by the hospital to stick to its own policy on patient grievances.
Much of the January report centered on a patient who had fallen and was brought to CMMC’s emergency department by ambulance on the morning of Oct. 4, 2018. The patient had previously been diagnosed with herniated disks and a compression fracture of a vertebra, according to the federal report. The patient was at his spinal surgeon’s office when he bent forward, felt lightheaded and fell on his head.
At CMMC, according to the report, the patient complained of neck pain, back pain and numbness to the right half of his abdomen and down his right leg. A CT scan showed a skull fracture and a small fracture with fragments to one of the bones in his neck. The patient’s care was transferred from the emergency doctor to a trauma surgeon.
By that afternoon, the patient was complaining of tingling and numbness from the chest down. The trauma surgeon had the patient move his head and neck “in every possible way” to determine range of motion.
“This is contrary to the standard of care for a patient with a known cervical fracture,” the report said.
The report also said there was no evidence anyone looked at the patient’s previously broken vertebra to see if the fall had worsened it.
At some point after that, according to the report, a nurse entered the patient’s room and proceeded to raise the head of his bed, forcing the patient, who had been lying flat, to sit up at a 45-degree angle — over the protests of a family member, who told the nurse the doctor had ordered the patient to remain flat.
As the nurse raised the bed, the patient screamed in pain.
“The family member reported the nurse’s response was, ‘The doctor ordered him to be sat up,’” the report said.
According to the report, a neurosurgeon noted in the patient’s medical record the patient had “lost all movement since that time.”
CMS initially told the hospital it would no longer pay for Medicare patients admitted to the hospital beginning May 4 unless CMMC addressed its problems. That decision would also affect the federal portion of Medicaid payments.
Last week, CMS extended its deadline, giving the hospital until June 30 to make improvements.
However, CMS noted additional investigations in March and April found more or continuing problems at CMMC, including failure to ensure medical records were accurate and failure to document whether patients had an advance directive to guide their treatment.
The March investigation also found CMMC, which includes a nationally accredited heart center, failed to care for a patient who arrived in the emergency department at 5:13 p.m. on Jan. 22 with chest pain, dizziness, shortness of breath and blood pressure so high it met the American Heart Association‘s criteria for a “hypertensive crisis.”
“(It) felt like my heart was stopping, then it would start up again double-time,” the patient told the investigator. “It scared me.”
The patient received an EKG within seven minutes, and that test came back normal.
However, according to the report, nothing else happened for almost two hours. No one checked on the patient’s chest pain or blood pressure. The patient was not attached to a heart monitor. The patient was never seen by a medical provider, and no medical provider was assigned to the case until 7:10 p.m.
That emergency department doctor took the case for only three minutes, just long enough to order two medications and a blood test that determines heart muscle damage. That doctor said she never saw the patient and only realized the patient needed a doctor when she spotted the patient in a room without a provider assigned.
The patient left after two hours, minutes after the doctor ordered the medication and blood test.
“I remember feeling bad because I was not told about this patient,” the doctor told the investigator.
The report said that, according to chest pain protocol, the patient should have been treated as a level 2 emergency. Instead, the patient was classified as the lower level 3.
When the investigator asked the triage nurse about the chest pain protocol, the nurse said, “Well, I’m sure an actual protocol exists somewhere deep in the computer system/files, but we go by what we think and compare their symptoms for the triage level guidelines we have.”
This is the second time in less than a year CMS has ordered the hospital to fix problems.
Last summer, inspectors found CMMC had called police on an uncooperative emergency patient. That patient was removed without being seen by a medical provider, and staff deleted the patient from the emergency department’s registration log. Investigators also found the hospital had instructed police and ambulances not to bring in patients with mental health problems because it does not provide services for them.
Those acts violated a federal law requiring all hospitals receiving Medicare funding to screen and stabilize anyone who shows up at the emergency room requesting treatment.
At the time, CMMC submitted plans detailing how it would correct the violations, allowing it to continue receiving Medicare payments.
It is unclear exactly how much money CMMC would lose if CMS refuses to pay for patients admitted there. In tax paperwork for fiscal year 2015, the most recent year available, CMMC reported receiving $72 million from Medicare.
It is unusual for a Maine hospital to lose Medicare payments. The last Maine facility to lose funding was the state-owned Riverview Psychiatric Center in Augusta. The federal government pulled Riverview’s certification in 2013, citing a number of problems, including the use of stun guns and pepper spray and the improper use of restraints on patients. It was not recertified until this year.
In the statement released Thursday, CMMC leaders were adamant their hospital will not end up losing funding.
“We are confident that all requirements will be met and CMMC will continue its relationship with CMS,” the statement read.
The hospital must submit to CMS a plan for correcting its issues. To help determine whether CMMC is moving in the right direction, investigators will make an unannounced visit to the hospital.
“In extending the termination date, we emphasize that your facility’s compliance must be verified … in order for termination proceedings to be rescinded,” CMS wrote last week in a letter to the hospital’s president.
The Maine Department of Health and Human Services released a statement Thursday that said the department’s Division of Licensing and Certification “is working closely with federal regulators on this matter.”
“A termination notice by CMS would affect federal Medicaid (MaineCare) payments to Maine as well as Medicare payments to CMMC,” the statement read. “The department is prepared to conduct outreach to MaineCare beneficiaries, health providers, and the public if the hospital is decertified.”
CMMC is the flagship hospital of Central Maine Healthcare, one of the largest health systems in the state. The system has been in turmoil for months, including votes of no confidence in system CEO Jeff Brickman, the resignation of the president of Bridgton and Rumford hospitals, the exodus of medical professionals across the system, a call from a citizens’ group for the system to pull out of Bridgton and, two weeks ago, the resignation of board member Phil Libby.
The day after his resignation, Libby told the Sun Journal: “Personally, I’m concerned about my personal liability … as a director. I was not and have not been happy with the direction that the organization has been taking.”