Becker's Hospital Review

41 FINANCE CMO / CARE DELIVERY MD Anderson patient died after contaminated blood transfusion, CMS says By Mackenzie Bean A 23-year-old leukemia patient died aer receiving a contaminated blood transfusion at MD Anderson Cancer Center, according to a CMS report made pub- lic June 24 and cited by the Houston Chronicle. e report came two weeks aer news broke that CMS found serious care deficiencies at the Houston-based hospital. Regulators in- vestigated MD Anderson aer the hospital reported an adverse event involving a blood transfusion in December 2018. e specific circumstances of the event were not made public until June 26. e CMS report says a female patient with leukemia died two days aer receiving a blood transfusion contaminated with bac- teria. e report also noted the patient had serious complications before receiving the transfusion. "While it is unfortunate that the CMS surveys resulted from an adverse patient event, we rec- ognize and embrace the opportunity to further enhance and improve our patient care efforts and robust safety measures," MD Anderson said in a statement on its website. "We take this feedback seriously, and we already have imple- mented changes into our clinical practice." e hospital implemented new safeguards for blood transfusions and is providing ongoing education on blood administration proce- dures, among other efforts. MD Anderson also sent CMS a correction plan to address deficiencies June 21. Regulators are expected to revisit the facili- ty in July to determine if the hospital has re- gained compliance to federal standards. n Training lapses may have led to rise in C. diff infections at VA hospital: 5 findings By Anne-Marie Kommers F ailure to adequately train housekeeping staff may have contributed to growing rates of potentially deadly infections at Loma Linda, Calif.-based Jerry L. Pettis Memorial Veterans Hospital, according to a re- port released June 18 from the Department of Veterans Affairs Office of Inspector General. Five findings from the report: 1. The report confirms a separate 2018 VA investigation, which found the medical center's executives hid infor- mation from staff on the presence of Legionella bacteria in the water system. Data from the center found 33 posi- tive water test results for Legionella from 2017 and 2018. 2. The new report also found the medical center was un- clean and had furnishings in disrepair. The center's en- vironmental management services department had no standard procedure for cleaning and facility sanitization. 3. The lack of housekeeping training may have been a contributing factor in a two-year increase in Clostridium difficile infections at the medical center, with 32 cases in 2016 and 36 in 2017. 4. Five hundred and thirty-four medical center staff members failed to consistently undergo required blood- borne pathogens training during the period of May 2016 to March 2018. 5. The hospital received one star from the VA in 2018 for its medical facilities, which is the lowest possible rating. n Georgia health system was blindsided by 12-cardiologist exodus By Emily Rappleye A report from The Gainesville Times reveals Gaines- ville-based Northeast Georgia Health System is still not sure what caused the sudden departure of 12 cardiologists in June. The cardiologists, previously employed by the Heart Center of Northeast Georgia Medical Center, moved to the neigh- boring Northside Hospital, based in Atlanta. The departing cardiologists included the chairman of the heart hospital, Jeff Marshall, MD. NGMC Gainesville President Louis Smith told The Gaines- ville Times that the cardiologists and health system were in the process of renewing contracts. Physician leadership had approved the contracts, and the health system expected them to be signed. However, some of the cardiologists had not returned the paperwork as of May 31, when their con- tracts were set to expire. Even then, Mr. Smith thought they would sign and return the contracts by the following week, according to the report. Mr. Smith first realized something was off when several phy- sicians called in to say they would not be reporting for their shifts. An attorney sent the health system a letter on June 1 announcing the departure on behalf of the cardiologists, according to the report. The health system is still working to understand what caused the departure. NGMC is currently hiring to fill the positions. It still has 26 phy- sicians and 42 advanced practice providers on staff, so patient care will largely go uninterrupted, according to the report. n

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