Ballad Health Downgraded Holston Valley’s Trauma Center, a Patient Died… a Subsequent Report by TN Department of Health Determines “Rules and Laws Were Violated”.
“Dear Ms. Cook:
On March 3–10, 2020, a surveyor of this office made an unexpected visit to Holston Valley Medical Center to investigate your complaint. The surveyor used the specific concerns you relayed in your complaint to review compliance with regulations that most closely related to your concerns…
The surveyor did find that rules and laws were violated at the time of our visit. The Agency will take action, since the surveyor determined the facility was not doing what they were required to do at the time of the inspection.”
I received this letter in April 2020 following a complaint I filed with the TN Department of Health Licensure for Health Care Facilities in February 2020. While the initial purpose of my call was a concern regarding the “cluster deaths” following cardiac surgery at Ballad Health’s Holston Valley Medical Center (that story to come later), I did share concerns related to more than one incident including the death of Jeremiah Fields.
I first became aware of Jeremiah’s death while outside Holston Valley protesting the downgrade of its Level I Trauma Center and Level III Neonatal Intensive Care Unit. The memory is as clear as if it had happened yesterday. Under tarp-covered canopies, a beautiful red-head whose face was worn with grief and emotional exhaustion asked to share her story with me. I cannot tell you how long we spoke or how long we sat together, but what I can say is that what I heard broke my heart and changed me forever.
Jennifer, Jeremiah’s fiancé, told me that he had been in a rollover motor vehicle accident where he was ejected in the late evening of Saturday November 9, 2019. Through her tears and heartbreak, Jennifer talked about Jeremiah’s extremely low blood pressure readings that weren’t addressed, his extreme pain, sweating profusely, and her repeated requests for the hospital personnel to do something. I saw pictures of Jeremiah lying in the hospital bed. I listened to an audio of him calling out for God to help him because he believed he was dying. Jennifer’s mother would testify about these very things at the Annual COPA Public Hearing on January 7, 2020. (transcript here)
That’s why Jeremiah’s story was still fresh in my mind and part of the concerns I relayed to the TN Department of Health several months later. In the weeks that followed, COVID-19 became a reality and following up on the violation letter, regrettably, was pushed from the forefront of my mind. In fact, with the exception of major public health issues specific to Ballad, my reporting on healthcare in the region was paused.
In August, one such issue happened.
On August 20, 2020, Ballad Health released a statement that Bristol Regional Medical Center CEO, Greg Neal, was resigning. Within hours, I received information from several sources close to the matter who alleged that Neal had participated in a cardiac surgery with Dr. Nathan Smith, making the initial incision into the patient’s chest, despite having no medical licensure or training. On August 24, 2020, I broke the story regarding these events and subsequently, Ballad Health confirmed the story the next day.
It was this incident and the subsequent amendment of charges that brought me back to the violation letter I’d received in April 2020 and the documents I’d received from the TN Department as a result of a FOIA (Freedom of Information Act) I’d filed with them at the time I made the complaint.
I had no idea what laws or rules the violation letter was in reference to because it didn’t contain any specific information other than it was directly related to the information I provided. My initial thought was that it was in reference to the “cluster deaths”. So, I immediately began looking through the FOIA documents I’d received and contacted the Regional Office of the Licensure for Health Care Facilities to ask for additional information on the letter.
While speaking with a supervisor, I was informed that either the Board of Health Care Facilities or the Commissioner of Health would be responsible for determining if disciplinary action would be taken.
Given the fact that the Tennessee Department of Health had not taken any disciplinary actions after Greg Neal made the initial incision into the chest of a patient during cardiac surgery, I became even more curious as to what laws had been broken regarding the complaint I filed. I mean, how egregious does a violation have to be in order to have disciplinary action taken by the Department of Health? After all, this agency is legally tasked with providing “active supervision” over Ballad Health, a literal medical monopoly, to ensure any disadvantages that resulted from their “merger” and subsequent loss of competition don’t outweigh the advantages.
As directed by the TDH supervisor, I emailed Mae Copeland and requested a copy of the Statement of Deficiencies. I also contacted CMS, Centers for Medicare and Medicaid. I never received a response from the Ms. Copeland at the TN Dept. of Health, but I was successful in getting the document from CMS.
Below, are the five rules and laws cited in the Form 2567 Statement of Deficiencies and Plan of Correction as being violated by Ballad Health regarding the death of Jeremiah Fields.
A-0084 CONTRACTED SERVICES CFR(s): 482.12(e)(1)
The governing body must ensure that the services performed under a contract are provided in a safe and effective manner.
From the report: “This STANDARD is not met as evidenced by: Based on medical record review and interview, the facility failed to ensure contracted medical staff assessed a patient with a change in condition, resulting in Patient #1’s continued decline and subsequent respiratory and cardiac arrest.
Part of the decline this report references are the blood pressure recordings Jennifer had told me about while outside Holston Valley. Below is an excerpt of those readings detailed in the report:
12:00am 139/78
1:00am 116/76
2:00am 104/77
2:15am 74/47
2:30am 76/50
4:00am 86/42
4:15am 73/29
4:30am 54/12
According to the report, the medical record review of a Nurse’s Note showed the nurse called the physician at 4:00am and a second nurse called at 4:52am, the documentation did not specify the nature of the call.
A-0286 PATIENT SAFETY CFR(s): 482.21(a),(c)(2),(e)(3)
This refers to the program’s responsibility to “track medical errors and adverse patient events, analyze their causes, and implement preventative actions and mechanisms that include feedback and learning throughout the hospital.”
From the report: “This STANDARD is not met…”
The surveyor documents in this report that she reviewed an “undated facility investigation” and an “undated plan of correction” regarding the “adverse event” (Jeremiah’s death).
These findings are of extreme significance to the public because just a couple of weeks prior to this interview, Lindy White, CEO of Ballad Health’s Northwest Market that oversees Holston Valley Medical Center and Bristol Regional Medical Center released a public statement about their dedication to internal investigation and self-reporting requirements following “ANY patient death”. Yet, the report states that in her interview with the surveyor, Ms. White stated “there was not a written plan for the implementation excluding Intensive Care Unit Charge Nurses from staffing and the facility was not monitoring how often the Charge Nurses were assigned patient care.” It also states “The CEO was unable to show documentation for monitoring the effectiveness of the facility’s plan of correction.”
In addition, the Director of Risk Management stated “the facility could not provide a plan for ensuring the Charge Nurse would not be included in staffing and assigned patient care and could not provide documentation to show the radiology technicians were educated after the incident… as outlined in the facility’s plan of correction. The Director of Risk Management was also unable to provide documentation of the education provided for new graduate nurses and was unable to provide documentation of the staff members who received education regarding physician notification of a change in a patient’s condition.”
That’s right. Not only were the facility investigation and plan of correction undated, Ms. White and the Director of Risk Management could not produce documentation showing they had actually implemented any items listed in them to prevent this same type of adverse event from happening again.
The next violations listed in the Form 2567:
A-0385 NURSING SERVICES CFR(s):482.23
The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse.
A-0392 STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b)
The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient.
The reported noted in several places the violation of the Charge Nurse “in staffing”, meaning that the Charge Nurse had a patient assignment of their own which would impact their ability to supervise the care for the new graduate handling Jeremiah’s care.
A-0529 ORDERS FOR RADIOLOGY SERVICES CFR(s): 482.26(b)(4)
Radiologic services must be provided only on the order of practitioners with clinical privileges or, consistent with State law, of other practitioners authorized by medical staff and the governing body to order the services.
This is a STANDARD that was not met because “the facility failed to ensure an immediate (STAT) follow-up chest x-ray was completed” for Jeremiah. He was hospitalized with a Chest Flail, described in the report as “a life-threatening medical condition where a segment of the rib cage breaks and becomes detached from the rest of the chest wall).
The Chief Medical Officer stated in a telephone interview with the surveyor that an x-ray was done during the resuscitation and Jeremiah “had a chest full of blood… opportunities were missed along the way…”.
The surveyor’s report states that the “undated facility investigation” noted:
- The nurse caring for Jeremiah was a “new graduate RN”
- The MICU (Medical ICU) Charge Nurse “in staffing [had a patient assignment”
- “No provider/residents in house [physician]”
- “Locus [a contracted Physician who temporarily fills a position] not readily available”
- “RN did not ask MD [Medical Doctor] to assess patient in person”
- “RN failed to manually check BP [blood pressure]”
- “duplicate x-ray orders 2 charts open at the same time resulted in rad tech [radiology technician] cancelling one order and other was also cancelled…”
If necessary, read those violations and findings again and then ask yourself these questions:
- Where is the self-reporting that Ballad Health claims they are required to execute?
- Where is the disciplinary action by the Tennessee Department of Health or CMS?
- Is this what the legislators intended by “active supervision” when they wrote the COPA law that created the medical monopoly, Ballad Health, that is responsible for almost all the inpatient care of 1.2 million people?
Four “Standards of Care” and one “Condition of Care” were found to be violated and the only reason the public knows… the only reason Jeremiah’s family knows… is because Jennifer came inside a tarp-covered canopy back in November 2019 with a broken heart and disheartening story about the care, or lack thereof, she witnessed. The details and her devastation kept Jeremiah’s story close to my heart and months later, in the complaint I filed.
That complaint resulted in the Violation Letter.
The Violation Letter led me to the Statement of Deficiencies.
The Violation Letter led me to the truth.
Now, we all know what happened to a trauma patient just five weeks after Ballad Health downgraded Holston Valley Medical Center from a Level I to a Level III facility.
Believe it or not, you still don’t know everything. Stay tuned.
Note: This is the first in a series of articles regarding this event and other relevant information.
