St. Luke’s back in compliance with feds
CEO hails significant step in restoring trust in historic hospital after patient death, probe
The federal government has relinquished the greater oversight it assumed over Baylor St. Luke’s Medical Center earlier this year after a patient death, a significant step forward in the historic Houston hospital’s hoped-for road to recovery.
Centers for Medicare and Medicaid Services officials notified St. Luke’s late last month that it is again in compliance with the agency’s conditions of participation and its supervision has been transferred back to its accrediting body, said Doug Lawson, CEO of the medical center.
“Successfully completing a CMS review process of this magnitude within sixmonths is a tremendous accomplishment,” Lawson wrote in a statement sent to employees Monday and released to the Chronicle on Wednesday. “We have created an amazing foundation on which we will continue to grow a culture of excellence that will ensure a quality, safe patient experience.
CMS had taken more aggressive oversight of St. Luke’s, known as removing its “deemed” status, after an investigation into the death found numerous safety and patient-care deficiencies. That death, involving a blood transfusion error in the emergency room, was the last straw that led the St. Luke’s board of directors to oust the medical center’s former president, chief nursing officer and a top physician.
A yearlong investigation by the Houston Chronicle and ProPublica already haduncoveredanddoc
umented an outsized number of deaths and unusual complications following heart transplants at St. Luke’s. CMS in August 2018 terminated federal funding for heart transplants at the hospital, citing its failure to make changes needed to improve outcomes.
CMS’s 2019 revocation, which placed St. Luke’s under increased government oversight, did not result in the termination of any fund
ing for the overall hospital.
But in February CMS notified St. Luke’s that deficiencies throughout the hospital were “of such a serious nature as to substantially limit your hospital’s capacity to render adequate care.” The deficiencies were noted after a team of federal and state inspectors descended on St. Luke’s following the death, first in January, then again in March and April.
In May, CMS detailed the deficiencies in a 203-page report. Those included a pattern of blood labeling errors, patients given
medications not ordered by their doctors, objects mistakenly left in patients after surgery and sewage backed up into a kitchen stocked with moldy vegetables.
St. Luke’s subsequently submitted a 129-page plan of corrective action, which included fixes to the hospital’s kitchen equipment and several policy, staffing and training changes aimed at correcting each of the deficiencies.
Federal and state inspectors returned for a follow-up inspection in June, at the end of which they told St. Luke’s leaders they had
completed its survey ahead of schedule and cleared the hospital of all serious deficiencies. On July 25, a CMS enforcement officer wrote Lawson that its deemed status had been official restored.
CMS funding of the heart transplant program remains terminated. Baylor St. Luke's Medical Center dropped its appeal of that decision in April, still focused on rebuilding the program and planning to apply for CMS certification later this year.
Two other Texas Medical Center hospitals still lack deemed status. MD Anderson Cancer Center’s was removed following the death of a patient who received contaminated blood, and Ben Taub Hospital’s was removed following the death of a patient discovered without a pulse in an ER bathroom more than a day after lab results showed his condition was critical. A month after that case became public, Ben Taub revealed another ER patient had recently died in a waiting room restroom.