BENNINGTON -- Southwestern Vermont Medical Center was investigated by state officials last week after two emergency room nurses failed to immediately care for a patient showing no signs of life.
According to a release distributed by SVMC Monday, the patient in question arrived at the SVMC Emergency Room complaining of back pain.
Following an initial assessment by nurses, the patient was found dead by a non-clinical staff member shortly thereafter. The staff member then notified the two nurses who were initially caring for the patient, but neither responded.
A physician was later alerted of the death by an additional nurse, per the release.
According to SVMC officials, the patient's cause of death is unknown. An autopsy has been ordered but the results are unavailable at this time.
SVMC reported the incident to the state on Oct. 2, hospital officials said, and an investigation was carried-out by state surveyors five days later.
Following the investigation, it was determined that SVMC staff members failed to follow various hospital policies, including those related to patient privacy, reporting adverse events, and treatment consent.
"I am upset and disappointed that we did not live up to our own high standards for the care that we provide and that our community expects," Thomas Dee, president and CEO of Southwestern Vermont Health Care, said in the release. "We are committed to being transparent with regulatory agencies, our staff, patients and families, and our community. To that end, we reported the incident ourselves. We already have taken steps to see that this does not happen again, and have discussed the incident with the family and offered them our apology and our help in understanding what happened and the steps we have taken to address the problems."
Dee went on to say that the state, which acts as a proxy for the Federal Centers for Medicare and Medicaid Services (CMS), is obligated to cite the hospital for "failing to maintain proper standards."
This could potentially culminate in SVMC no longer participating in the federal Medicare program.
However, he noted that a citation like the one SVMC was issued is not uncommon, especially in instances as serious as this one.
The hospital is required to correct its deficiencies and will be re-evaluated by the state in the near future.
"At this survey, we expect CMS to accept our plan of correction and certify that SVMC remains a full participant in compliance with Medicare's standards," Dee said in the release.
Dee explained that the hospital management took immediate steps to address the incident and that further changes are expected soon.
According to hospital officials, SVMC has already restructured its nursing leadership within the emergency department, developed a system which ensures a constant presence of strong leadership in the emergency department, and held discussions with clinical staff, reinforcing the culture of patient safety, the duty to immediately report and identify unsafe behaviors or conditions, and instituted a requirement for health system staff to undergo intensive, interactive education sessions on patient safety and hospital policies.
"This event is a clear call to action," Dee said. "Our entire team, throughout the health system, will not rest until we see SVMC return to full compliance with Medicare. We are confident that this incident does not reflect the quality of our staff or the care that we provide, and we are determined to demonstrate this fact to our patients and their families going forward."
Hospital Spokesman Kevin Robinson said Monday that the names of the patient and the two nurses involved, as well as the actual date of the incident, could not be released due to both federal privacy laws and personnel confidentiality measures. He did confirm that both nurses in question, who are licensed registered nurses, are no longer treating patients at SVMC.
However, Robinson could not confirm whether the nurses remain employed by the hospital.
Contact Elizabeth A. Conkey at email@example.com or follow her on Twitter @bethconkey.