To Whom It May Concern
RE: S. B. v. Fayetteville, NC Veterans Administration Medical Center(VAMC)
My name is ****************** and I serve as a consultant to hospitals and attorneys regarding hospital administrative issues. I have been a hospital chief executive officer and hospital administrator and currently am a consultant to hospitals and health systems throughout the United States. I am a Board Certified Hospital Administrator and a Fellow of the American College of Healthcare Executives, which is the professional organization for hospital administrators. I have lectured extensively to hospital administrators and graduate students in hospital administration and have been a featured speaker at several national meetings. I am currently a faculty member in the graduate and undergraduate health administration programs at the University of *****, **** University, and ****** University. I have also written a book entitled ************************** for the Hospital, and I recently contributed a chapter to an ACHE book entitled ***********************************************************. I have been employed in the field of hospital and healthcare administration since 1973. I am familiar with the prevailing professional standards of care for acute care hospitals. I have been actively involved in the management of acute care hospitals, including their emergency departments. Further information regarding my experience and qualifications is detailed on my CV.
At your request, I have reviewed medical records regarding the care given to Mrs. B at the VAMC. I have also reviewed the expert report of Dr. M, as well as the 2012 Hospital Accreditation Standards Manual of the Joint Commission and the Federal Emergency Medical Treatment and Labor Act (EMTALA).
While forming my opinions, I have relied on my training, experience, and expertise in hospital administration gained from over 35 years in the field. I will also utilize and refer to the Joint Commission (JC) standards that were in effect in 2012, and use them also as evidence of standards for corporate responsibility for the VAMC in this case. These Joint Commission standards are widely accepted in the United States as the standard of care for the provision of inpatient hospital care, and describe the accountability and responsibility of hospital leaders in the delivery of care at their facilities. They are accepted by the Veterans Administration as guidelines for their hospitals. Joint Commission standards require that hospital leaders establish a governance structure and management systems to oversee that appropriate rules, regulations, infrastructure, credentialing, and communication processes are in place to deliver high quality and safe care to their patients. The hospital is further required to establish systems to monitor the effectiveness of care and to correct any deficiencies. Ultimately, the hospital is responsible for the oversight of all professional services provided by its medical staff, employees, and any others that it credentials or contracts with to practice at the hospital. Joint Commission standards are also used by the federal Centers for Medicare and Medicaid to determine compliance with the requirements of these programs and are also used and accepted as the standard of care for hospital licensure in many states, including North Carolina. In addition, the Veterans Health Administration, in its published directives, notes that it complies with the JC Hospital Accreditation Standards, as well as the EMTALA regulations discussed below.
A brief summary of this case indicates that Mrs. B presented to the VAMC unaccompanied and driving her own car at 3:52 A.M. on February 25, 2012. She reported that she had fallen at home after taking sleep medications prior to arriving. After ruling out a fracture to her arm, Mrs. B was discharged alone and unaccompanied at 5 A.M., even though she was evaluated as being “sluggish and sedated”, as noted in her chart. Shortly after leaving VAMC, she drove off the road, hit a tree, and was killed on impact.
It is my opinion, based upon my experience as a hospital administrator and consultant, within a reasonable degree of professional certainty that the care provided to Mrs. B by the VAMC and its medical staff and employees was not consistent with certain specific JC standards detailed below, and therefore violated such standards.
JC Standards for Hospital Leadership (LD) provides guidance on the governance and management of the hospital, as well as the delivery of care by all physicians, nurses, and others. Leaders are ultimately responsible for planning, directing, and providing all care delivered to patients.
LD.01.03.01,” The governing body is ultimately accountable for the safety and quality of care, treatment, and services.”
The VAMC is fully and completely responsible for the actions of its staff, physicians, agents, and all independent contractors regarding the care that is delivered to its patients. As discussed in this report, and documented by Dr. M. in her report, Mrs. B did not get the quality of care she should have received.
LD.04.01.01, “The hospital complies with law and regulation.”
While the information provided to me is incomplete at this time, there is indication that VAMC and the emergency department physician did not fully comply with the Emergency Medical Treatment and Active Labor Act, 42 Code of Federal Regulations (EMTALA), which requires that all patients be evaluated and stabilized prior to being discharged from the emergency department. As indicated in the report of Dr. M., Mrs. B was discharged while under the influence of her sleep medications and was sent home by herself. VAMC is required to comply with the EMTALA regulations by their own policy.
LD.04.01.07, “The hospital has policies and procedures that guide and support patient care, treatment, and services.”
The standard further states, Element 2, “The hospital manages the implementation of policies and procedures.” Hospital policies should have been in place to make certain that Mrs. B was fully assessed prior to discharging her from the hospital. Further, there should be policies that describe the responsibilities of hospital emergency department staff to comply with EMTALA regulations to evaluate and stabilize each patient presenting to the emergency department.
JC Standards for the Provision of Care, Treatment, and Services (PC) are designed to define the successful coordination and completion of patient care processes, including the assessment of patient needs, the planning for care, the actual provision of the care needed and the overall coordination of all patient care services.
PC.01.01.01, “The hospital accepts the patient for care, treatment, and services based on its ability to meet the patient’s needs.”
PC.01.02.01, “The hospital assesses and reassesses its patients.”
Each of these standards speaks to an element of care that VAMC owed to Mrs. B. She was accepted for care in the emergency department and should have been fully assessed and reassessed regarding the medications she had taken and the fact that she had already complained of a fall at home. Instead, VAMC staff only evaluated the possible arm fracture, and allowed Mrs. B to drive herself home, even though she was documented as being “sluggish and sedated.”
The various departures identified above from the mandatory standards of the Joint Commission and the EMTALA regulations adversely impacted the provision of necessary care and treatment for Mrs. B and, with a reasonable degree of administrative certainty breached the standard of care owed to her and resulted in her death from an automobile crash.
Should any additional information become available to me, I reserve the right to modify or supplement this opinion