HOUSTON - Harris Health System's Ben Taub hospital is facing sanctions from state and federal regulators after a patient died in the emergency center bathroom after waiting more than 24 hours for care.
The investigation by the Centers for Medicare and Medicaid Services clearly puts blame on the hospital and its staff in a 49-page report.
"The facility's action did put the patient's health and safety in jeopardy," the report states.
On April 11, 2019, a patient only identified as a 66-year-old Hispanic man came to the Ben Taub emergency room complaining of eight days of abdominal pain, loss of appetite, and vomiting. He was also diabetic.
He was seen by a patient care technician at 8 a.m., but he wasn't admitted and triaged until 12:46 p.m. He was never given a bed because there were not any available.
It was 1 p.m. the next day, April 12, when a security guard found the man in a waiting room bathroom appearing to need help. A nurse came but the patient said he was OK and the nurse left.
At 4:30 p.m. the security guard discovered the patient passed out on the same bathroom stall, covered in vomit and in cardiac arrest. He was pronounced dead at 5:34 p.m.
In a letter to Harris Health, CMS said the hospital was out of compliance due to significant deficiencies in the areas of patient rights and emergency services.
The report cited several failures related to the man's death that day: Patients were not monitored in a timely manner, complete medical screens were not conducted and critical lab tests were not reviewed, reported and acted upon.
Harris Health has submitted a plan of corrective action to state and federal investigators focusing on six areas:
1.) Response, escalation, timely clinical response to critical lab values
2.) Assessment and monitoring of patients in the emergency care waiting room
3.) Increasing staffing
4.) System-level mandatory reporting policy and event reporting notification matrix
5.) Emergency care census
George Masi, the president and chief executive officer of Harris Health issued the following statement to Channel 2 News:
“Harris Health is fully committed and working toward a speedy resolution of the findings and restoring the system’s deemed status. It is expected that Texas’ Health and Human Services Commission (HHSC) will soon conduct a resurvey to assess compliance with all of the applicable Medicare Conditions of Participation.
"Harris Health’s leadership takes this matter very seriously. Since completion of the first HHSC survey, Harris Health has made substantial strides in achieving full compliance and will continue to work diligently to meet all of the applicable standards of care.
"Be assured, each day, the entire Harris Health staff -- employees, medical staff, contractors and volunteers -- strives to ensure a safe environment for all of our patients.
"It is our highest priority to provide our patients the safe, effective care they rightfully deserve.”
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