Pasco patient needed crash team but hospital could not find his room; he died

It was just after 11 p.m. when a computer screen alerted a hospital technician that one of the 50 patients she was remotely monitoring had a potentially fatal change of heart rhythm.

Her screen also showed one of the wires attached to the patient had fallen off. Regardless, medical protocol required a code blue be called in case the patient needed resuscitation.

The patient had been admitted to HCA Florida Bayonet Point in Pasco County after a positive COVID-19 test, according to a state review of the hospital conducted in September. The hospital’s computer listed the patient as being on floor 2 West. But when the technician called the ward, a nurse said the patient hadn’t arrived. A call to the emergency department to find him wasn’t answered.

“I didn’t know where the patient was; I knew he needed help,” the technician told state investigators. “It didn’t seem reasonable to call a code blue to an empty room.”

About 20 minutes later, a nurse who went to administer medication found the man lying “across” his bed. Fluid was coming out of his nostrils. He could not be revived.

A state review of the hospital found that the patient’s room number was incorrectly logged into the hospital’s computer system by a registrar. It also highlighted multiple safety concerns at the Hudson hospital, including some that contributed to the death of the patient and left others at risk.

The hospital did not have enough medical staff on its surgical intensive care and progressive care units, meaning nurses were assigned too many patients, the review by the Florida Agency for Health Care Administration concluded. Bayonet Point, the only trauma center serving Pasco, Hernando and Citrus counties, also failed to conduct appropriate remote monitoring of patients’ vital signs, putting them at risk.

Those shortcomings were considered Class 1 violations, signifying imminent danger to patients. The designation typically requires hospitals take corrective action within 24 hours.

HCA spokesperson Debra McKell said in a statement emailed to the Tampa Bay Times that the hospital chain has in recent months overhauled the leadership at Bayonet Point. The company in August named Sally Seymour as the new CEO and has also appointed a new chief medical officer and chief nursing officer.

The new leadership team is working with the state agency and the Centers for Medicare & Medicaid Services to ensure that corrective action plans in place to address staffing and quality concerns are followed, according to the statement.

“As the only trauma center in the area and provider of high-level services, including comprehensive stroke, cardiac and inpatient rehabilitation, we will continue our focus on providing the community we serve with quality health care services,” McKell said.

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The state report found that two of three hospital units reviewed were sometimes understaffed. The hospital’s surgical intensive care unit is required to have one registered nurse for every two patients with assistance from a charge nurse who should not be assigned any patients, according to its staffing plan.

But staffing schedules showed that the charge nurse was frequently assigned patients while some nurses were assigned as many as four patients. There was a similar issue on night shifts in the progressive care unit, where staffing levels provided by the unit’s manager understated how many patients nurses were assigned, the review stated.

In addition to the patient death, the state review spotlighted a patient who was transferred to a ward at 3:17 p.m. for monitoring but wasn’t connected to equipment recording vital signs until 10 p.m., a seven-hour delay.

The overhaul of the hospital’s leadership was made after a spate of other issues emerged.

In March, congressional lawmakers Sen. Marco Rubio and Rep. Gus Bilirakis wrote to the hospital’s former CEO, Regina Temple, demanding to know what the company was doing to address safety concerns reported by doctors and other medical staffers to NBC News. Those included cockroaches in operating rooms, unsanitary surgical instruments, inadequate monitoring of intensive care patients and people waking up during surgery.

One month earlier, a National Labor Relations Board investigation found that the hospital interrogated employees about their union activity, threatened them with termination or other reprisals and created the impression that workers discussing unionization were under surveillance.

The Accreditation Council for Graduate Medical Education in April placed the hospital’s internal medicine residency program on probation. The agency declined to provide information on the reason for the decision.

The Times shared a copy of the state’s review of the hospital with Bilirakis. In an emailed statement, he said he welcomes the appointment of new leadership but wants to hear from them what actions have been taken to prevent future problems.

“These newest allegations that hospital deficiencies contributed to a patient death are obviously concerning,” Bilirakis said. “Patients deserve confidence that they will receive the best possible care when seeking medical treatment and this hospital should work diligently to re-establish that trust.”