Cape Fear Valley’s ER is under fire over complaints of long waits and maltreatment [The Fayetteville Observer, N.C.]

Nov. 14--The emergency room at Cape Fear Valley Medical Center -- besieged for years with complaints of long wait times and too few beds -- is again under fire, this time for serious allegations that have led to two lawsuits and federal threats to fix the problems or lose Medicare reimbursements.

The first allegation, a complaint made early this year, resulted in a state investigation that found the emergency room had repeatedly failed to reassess the health and medical conditions of patients in the waiting room within four hours, as required by the contract for hospitals that accept Medicare patients.

As a result, the Center for Medicare & Medicaid Services issued a warning letter to the hospital to either adhere to regulations or face losing Medicare reimbursement on Dec. 29. Hospital officials say the recommended improvements have been made.

Then, in September, lawyers for the mother of a Fayetteville man filed a lawsuit alleging that negligence on the part of the emergency room staff and its security guards caused the death of her mentally ill son. Andre Walker died after the guards put him in a choke hold, according to the lawsuit. The death went uninvestigated for months.

That complaint led to another investigation, which put the hospital in "immediate jeopardy" with the Center for Medicare & Medicaid Services. The hospital was told to fix the problems by today or lose Medicare funding. State surveyors recommended Thursday that the "immediate jeopardy" status be lifted, a hospital official said.

This month, the lawyers involved with the choking case filed another lawsuit on behalf of a Fayetteville woman who alleged that she was kicked out of the ER and arrested while in severe pain from a kidney infection. Only when she began hyperventilating and throwing up, Ometric Snow said, was she treated and hospitalized for a week.

Cape Fear Valley officials acknowledge that the emergency room has problems, and they say they are taking them seriously.

But they also say the emergency room is safe for patients and staff and that wait times are continually improving, despite a patient load that has become one of the largest in the state.

Regardless, if complaints and violations continue, the Center for Medicare & Medicaid Services could lose faith in the hospital's ability or willingness to serve the public safely, said Stephen Frew, an Illinois lawyer who works as a risk and compliance consultant for hospitals.

"If the hospital doesn't demonstrate a sincere attitude toward correction, then it could get closed," Frew said.

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The Center for Medicare & Medicaid Services won't reveal the original complaint that led inspectors to review Cape Fear Valley's emergency room records in March. It did, however, provide the results of its findings that led to the mandate to fix problems by Dec. 29 or face elimination of Medicare benefits, which account for about 47 percent of the hospital's insurance payments.

According to documents provided by the state, inspectors found violations against the federal Emergency Medical Treatment & Labor Act -- known as EMTALA. Among other things, the law requires that hospital emergency rooms provide medical screenings and exams within a certain time frame, depending on the severity of a patient's complaint and condition.

According to state inspection reports, violations at Cape Fear Valley's emergency room included:

A 61-year-old woman came to the hospital on Feb. 21 by ambulance after slipping on a wet floor and hitting the back of her head. When she arrived in the ER, her condition was initially assessed. She complained of pain in her head, back and shoulder and told a triage nurse that her pain was at the highest level on the pain scale. X-rays and CT scans were performed in about an hour or less, but more than 6 1/2hours lapsed between her initial assessment and the time when nurses called for a reassessment of her condition. The patient had already left the hospital by then.

A 24-year-old woman arrived at the emergency room on Feb. 18 with sharp abdominal pains. She was initially assessed minutes after she got there, but hospital records showed the patient left the ER by the time nurses called to reassess her condition six hours and nine minutes later.

A 24-year-old woman suffering from a severe off-and-on headache arrived at the emergency room on Feb. 18. The woman's mother had recently died from a hemorrhagic stroke. It took six hours and 12 minutes between the time she was initially assessed and when nurses called her for a reassessment. The patient had already left the hospital.

A 50-year-old man who injured his groin in a fall came into the ER on Feb. 15 complaining of severe pain and swelling. His blood pressure was high, and he had a history of testicular cancer, according to his initial assessment minutes after he arrived. When he was called for a reassessment nearly five hours later, he had left, hospital records showed.

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The lawsuits filed in September and November make additional allegations, including that patient safety has been compromised by aggressive security guards at the hospital.

Hospital officials have declined to discuss the lawsuits on the advice of their lawyers. The hospital's emergency room service line director, Tim Wilcox, declined to comment about any of the allegations against his department.

Those allegations include the lawsuit filed by Valerie Walker, who says that her son, Andre, died after being put in a choke hold by hospital security guards in April.

She says hospital staff members left the area when the choke hold was applied. When they returned, the lawsuit alleges, they did not attempt to resuscitate her son quickly enough.

Walker said footage from a security tape shows that her son was not aggressive but merely agitated when he was restrained.

"He took a step toward the door," she said. "They got on either side of him, and his hands were like this -- folded. There was no resistance."

In viewing the tape, Walker said she watched her son's face fall as the medical staff abandoned him and left him with the security staff.

"He had more of a presence of security than of medical," she said.

Ometric Snow alleges that she also had a run-in with security guards at the emergency room.

Snow, who filed a lawsuit last week, said she was taken by ambulance to the emergency room on Oct. 18 while suffering from severe abdominal pain.

Snow, who has polycystic kidney disease, said the pain was coming from an infection that was also in her bloodstream.

While in the ER, she waited an hour, then asked for medication. When she was denied help, she said, she waited another hour.

Snow alleges that she asked for help again or for a transfer to another hospital. When she became frustrated and cursed, hospital security workers kicked her out of the hospital, she said.

Snow, who was holding blankets given to her by hospital employees, says in her lawsuit that she was approached by the security guards and told to hand over the blankets.

An argument ensued, and the security officer charged her with larceny of the blankets and obstructing an officer, Snow said.

As Snow was held in a security room, she started hyperventilating and vomiting. Medical staff attended to her, and she was hospitalized for seven days, according to the lawsuit.

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Frew, the compliance consultant, said the violations noted in state records are serious but not uncommon at hospitals. The allegations in the lawsuits, he said, are a different matter.

"Every hospital emergency room in the country is generally overcrowded, and that's because so many people lack insurance and lack primary care," Frew said.

As a result, hospital employees don't always take pain complaints seriously, especially when the patient is not bleeding or does not otherwise appear to be in immediate danger, he said.

In the 25 years since the federal law was enacted, Frew estimates that about 40 percent of hospitals have received deficiencies related to it. Of those, only about six or seven hospitals have been terminated from the Medicare program, he said.

Closing a hospital is rare because the Center for Medicare & Medicaid Services does not want to shut off the community's access to health care, Frew said.

But the allegations laid out in the lawsuits are considered extremely serious, Frew said, because they involve immediate patient endangerment.

Cape Fear Valley officials say they are taking all of the problems in the ER seriously and using them as a chance to change it for the better.

One of the biggest problems the hospital faces, however, is the number of patients who use the emergency room, said Vince Benbenek, a spokesman for the health system.

Since 2007, the emergency room has experienced a 28 percent increase in patient volume. During that time, ER visits jumped from 100,000 to 128,000, giving it one of the highest patient volumes in the state.

By comparison, WakeMed Raleigh Campus had fewer than 109,000 visits in 2010, while Duke University Medical Center's ER had about 70,000 visits.

"We're not the average American hospital," Benbenek said. "The volume is critical."

That's why the health system has made plans to build a 41-bed hospital in Hoke County and a 60-bed hospital in northern Cumberland County on Ramsey Street, he said.

But the expansions have come under fire by some residents who say the health system should improve the flagship hospital before building others.

Benbenek counters that expansion is the key to alleviating the high patient volume by spreading it out among more hospitals.

But, he added, it won't solve the problems the hospital faces now.

To relieve those problems, hospital officials hope a recent, $2.5 million renovation to the emergency room and moving the pediatric emergency room to another location will improve patient flow and wait times.

Benbenek said the renovation, completed a few months ago, has helped considerably so far.

"Right now, our average (wait time) -- and it still sounds crazy -- is four to five hours," he said. "But the national average is five hours, so we're within the national average. We're not happy with that because we think we can do better."

Benbenek said the staff has been trained on federal rules and regulations, as well, and the security personnel are receiving extra training as a result of the state investigations.

"This is stuff that's continually being addressed," he said. "We continually want to improve. We're getting better and better every day."

Benbenek pointed to another statistic that indicates improvement: The number of patients who leave without being seen has dropped more than 5 percent between the spring and October -- from 10 percent to 4.5 percent, he said.

"That's significant," he said. "It really is. At the same time, you talk to our (Chief Operating Officer Michael Harrington), and that's not good enough. We need to get it down to less than 2 percent."

But when it comes to some patients, the hospital has had a more difficult time, Benbenek said.

"We know how to do it right, but there's always those outliers," he said.

Potentially dangerous patients may require security or they may need to be removed from the hospital waiting area to protect staff and other patients, he said.

"This is not the norm. Ninety-nine percent of the time people come in, they've got a problem, it gets diagnosed, we put them through the system and they get better."

Staff writer Jennifer Calhoun can be reached at [email protected] or 486-3595.

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