NASHVILLE, Tenn. (WTVF) — Just two days before Ascension Saint Thomas faced losing its Medicare funding, the Midtown and West hospitals have been given a reprieve.
The federal government had put the hospital system on notice after Ascension Saint Thomas was unable to come up with what regulators considered an acceptable safety plan after that horrible drug mix-up at the Midtown location last month.
The immediate pressure is off at least for now for Ascension Saint Thomas to get its hospitals in order. But, according to the latest report, there are still a lot of problems that need to be addressed. The hospital has been given nine months to fix them. But, according to this report, the hospital has a long way to go.
The letter from CMS went straight into the Ascension Saint Thomas CEO's inbox Wednesday morning, informing hospital leadership that the Midtown and West hospitals are no longer facing the immediate loss of hundreds of millions of dollars in Medicare and TennCare funding.
Last month, CMS warned the hospital system that it had until September 18 to come up with a satisfactory safety plan to address the problems identified after four patients received the wrong drugs during knee replacement surgeries and wound up critically injured.
The investigation immediately after the medication mix-up by state regulators identified three separate immediate jeopardies or conditions that put patients' lives in danger. The hospital was told to come up with a safety plan to address the problems. It tried three times and failed each of those times.
We now have learned that it also tried a fourth time that was also unsuccessful. But then a fifth effort on September 2 apparently convinced regulators that the hospital was at least moving in the right direction.
Wednesday's letter, which was released by regulators, explains that "although the IJ (immediate jeopardy) immediate risks are removed, non-compliance remains..." meaning Ascension Saint Thomas is still not meeting required safety standards.
Regulators also released the latest findings from their investigation. And this report reads worse than the first one.
It also helps explain why now more than a month after the catastrophic drug mix-up, Ascension Saint Thomas is still not in the clear.
It goes into much further detail about what went wrong both before and after the patients got potassium phosphate injected into their spines instead of a common anesthetic. It also reveals many more significant and serious problems investigators identified when they went back to both hospitals for another round of inspections earlier this month.
Those inspections were meant to determine whether Ascension Saint Thomas had made changes to its safety systems to better protect patients after the August 14 mix-up.
According to their report, throughout the hospital, investigators found expired medical supplies and nutritional supplements, some dating back several years, that were being used and given to patients.
Half a dozen operating rooms had buckled or raised floors that investigators said made it impossible to clean.
And, employees failed to let antiseptic dry on patients in the operating room, increasing the risk of a surgical fire.
But perhaps most shocking was that the tragic drug mix-up on August 14 was not the only so-called adverse event there. In the just released survey, we learn there were 22 of them between August 12 and the 20.
And three of them happened in the compounding pharmacy at Midtown. There was catastrophic drug-error there that we already know about, but also two others, including what was referred to as a "near miss" on the 12th with incorrect labeling.
And even though the hospital was told right after the drug mix-up to immediately move all "high-alert" medications away from other drugs, investigators continued to find a long list of high-alert medications "intermingled" with other drugs, "without special labels or other visual differentiation."
And, there were many vials of NICU drugs, meant for the tiniest and sickest babies, right next to the adult strength versions, without any sort of special labeling, something one employee called "an error waiting to happen."
The hospital leadership team was also again called out. In the initial survey, investigators blamed management for creating "a culture of non-compliance."
The latest report goes even further, with regulators describing how they discovered on their most recent survey how Ascension Saint Thomas repeatedly failed to promptly investigate medication errors and adverse patient events, failed to take corrective and preventative actions after they occurred, and didn't follow up to make sure changes were implemented and evaluated.
And while CMS could have terminated its Medicare agreement with Ascension Saint Thomas — which would have been a devastating financial blow to the two hospitals and could have forced both to close — Wednesday's letter concedes that "CMS understands the impact that the termination of...the agreement would have on the community."
That's why regulators explained they decided to extend the termination date by nine months, until June 16, 2027, giving Ascension additional time to address the system noncompliance found during the surveys.
So, what happens now?
Ascension Saint Thomas says it's brought in a consultant to help both hospitals with oversight and getting into compliance. In the next week and a half, it has to submit a detailed plan outlining how it will address each deficiency. And after that, it will be required to turn in a monthly report showing that it's making progress.
For all of the negatives in this report, we did learn about some of the changes the hospital has made since the drug mix-up, including now that the pharmacy is no longer involved in compounding the spinal anesthesia. Now, the anesthesia team will get what it needs from an automated dispensing cabinet. What this means is that Ascension Saint Thomas will no longer be buying those drugs in bulk, as we've reported, and relying on the pharmacy to divide them into separate syringes, which is often cheaper, but will instead be buying individual vials which is what we learned most hospitals do.
Ascension Saint Thomas released a statement today acknowledging that it is no longer in immediate danger of losing its Medicare status. You can read the full statement below.
We did learn a bit more about the four patients from the inspection team. According to their report, one patient is no longer on ECMO, the heart and lung machine, and now has a tracheostomy to help him breathe. He apparently has some neurological issues and appears to be paralyzed.
The other three patients also continue to experience neurological issues, as well as paralysis.
Statement from Ascension Saint Thomas 9/16/26
"Today, regulators from the Centers for Medicare and Medicaid Services (CMS) validated the corrective measures implemented following the recent medication error at Ascension Saint Thomas Midtown, removing the Immediate Jeopardy (IJ) status. This confirmation ensures the hospitals remain active participants in the Medicare program, recognizes the corrective actions previously taken, and establishes an ongoing framework for demonstrating continued improvement in coordination with regulatory agencies.
We have engaged and continue to work with an independent quality consultant to guide and verify the full scope of our corrective actions and process enhancements.
At all times, our hospitals will remain open, operational, eligible for Medicare, and fully committed to serving the Middle Tennessee community.
We are grateful for our ongoing constructive collaboration with regulators, and we will continue to work with both the State of Tennessee regulators and CMS.
Our hearts remain with those impacted by this event, and we are committed to learning from this and upholding the standards of patient safety, quality, and compassionate care."
PREVIOUS RELATED REPORTING:
Ascension Saint Thomas also faces loss of TennCare money as well as Medicare money after drug mix-up
Ascension Saint Thomas West and Midtown hospitals face loss of Medicare funding after drug mix-up
Not all hospitals use their own pharmacies to prepare surgery drugs like Ascension Saint Thomas
State investigation into drug mix-up at Nashville hospital pharmacy finds multiple systemic failures
Woman paralyzed after drug mix-up in Nashville hospital pharmacy to begin intensive rehabilitation
Nashville hospital adds pharmacy safeguards after drug mix-up but why weren't they already in place?
If you or someone you know was affected by this medical mistake, I'd like to hear from you. Please email me at Jennifer.Kraus@newschannel5.com.
