Health Department Fines Staten Island Hospital for Deficiencies

$80,000 in Fines Must Be Paid Immediately and in Full – Corrective Actions Mandated

Albany, February 29 – Pointing to an alarming number of deficiencies related to quality assurance, reporting of medical errors, inadequate or poor use of staffing, and lack of proper procedures, the State Health Department today released findings from its investigation of Staten Island University Hospital and its neurosurgery service.

State Health Commissioner Antonia C. Novello M.D., M.P.H., said, "Our investigation found an alarmingly high number of deficiencies in the hospital's controls and procedures that need to be in place to ensure patients receive proper care. This Department will continue to ensure that all hospitals across the state take whatever steps necessary to make patient safety paramount. If hospitals are not operating at standards acceptable to the State Health Department to ensure patient care, this Department will act swiftly and decisively to hold them accountable."

"SIUH is an institution that did not have sufficient systems in place to prevent serious medical errors – and it also did not have critical systems in place to identify and correct such errors. The hospital must correct their deficiencies immediately and make certain such problems do not recur."

As a result of the investigation, the Department cited Staten Island University Hospital (SIUH) for 40 violations, resulting in fines totaling $80,000 against the hospital. The proposed fines amount to $2,000 per violation, the maximum monetary penalty allowable under State law. The hospital will also be required to submit a Plan of Correction (POC) describing how each of the identified deficiencies will be addressed, and what corrective action will be taken.

In addition, the hospital must obtain an independent consultant organization, acceptable to the State Health Department, to conduct an in–depth analysis of the management and oversight of SIUH's department of neurosurgery service.

Such analysis should include a thorough and comprehensive assessment of quality assurance, internal and external incident reporting, medical record documentation, communication within the service and with the Anesthesia Department and practitioner credentialing system. The analysis must produce a detailed report and recommendations for improvement for each of these activities, which must be provided to the Hospital's Board of Directors within 60 days.

Further, the SIUH also must obtain an independent consultant to analyze and suggest hospital–wide improvements to Quality Assurance and credentialing systems within 120 days. Once the hospital receives either consultant's report, recommendations must be implemented within 30 days, providing they are acceptable to the Health Department.

The hospital also will be required to submit quarterly reports to the Department for a period of one year commencing with the effective date of the Stipulation and Order. These reports shall detail activities undertaken to implement corrective actions and the assessment of the effectiveness of those corrective measures.

In a letter dated February 28, 2000, to Staten Island University Hospital, the Health Department cited 40 violations of Article 28 of the Public Health Law and the New York State Health facilities code. Deficiencies were cited in the areas of: Governing Body, Medical Staff, Quality Assurance Program, Patients' Rights, Incident Reporting, Medical Records, Surgical Services, Anesthesia Services and Radiology Services.

Specifically, the Department's investigation found:

  • Poor Judgement and Lack of Surgical Preparation: Examples include: starting a major neurosurgical procedure without having a copy of the CAT scan or x–ray or appropriate diagnostic test results in the operating room (OR); not having sufficient blood supply available in the operating room; not performing appropriate pre–operative testing before a procedure; requesting advice from a salesman in the OR; and using an inappropriate surgical device for the procedure being performed.
  • Inadequate Preparation of the Surgical Team, Lack of Sufficient Communications among the Surgical Team: Examples include: no discussion among the surgical team about the potential for doing a more extensive surgical procedure and assuring that the necessary preparations for that procedure were in place; concerns about the extent of a surgical injury were not fully identified or discussed; and the possibility about an incorrect site for procedures was not appropriately identified by surgical team members.
  • Inappropriate Use of Physician's Assistant: Physician's assistants routinely served as the first assistant in these major surgical procedures. This is a clear violation of the State Hospital Code and limited the advice and assistance available to the surgeon in these complex, life–threatening procedures.
  • Inadequate Quality Assurance: The quality of care deficiencies cited by the Department was not identified by the hospital's Quality Assurance System. No corrective action was proposed or implemented.
  • Staff Complaints Made to the Hospital Were Ignored: Hospital staff raised concerns within the hospital regarding the quality of neurosurgery care. No action was taken by the hospital to review these concerns until February 2000. When the chief neurosurgery anesthesiologist indicated that he would no longer work with a specific neurosurgeon in December 1999, such action should have triggered immediate review by the hospital's administration, medical staff leadership and quality assurance process. Nothing happened until early February 2000.
  • Failure to Report: The hospital did not report any of the cases cited in the Statement of Deficiency to the Department.

"Protecting patients and ensuring that they are receiving quality care is of the highest priority to this Department. We will continue to work with hospitals that want to improve their systems and procedures to meet our standards of care. And, we will continue to cite those hospitals that are derelict in their duties in a public way and with expediency," Dr. Novello said.

2/29/00–25 OPA