Days after CEO resigns, feds release investigative report on infection problems at Sparrow Carson

Carson City, Mich.-based Sparrow Carson Hospital failed to maintain an infection control program and properly document surgical site infections between January and October 2017, according to a recently released federal report cited by the Lansing State Journal.    

Here are six things to know.

1. The report's release comes on the heels of the departure of Sparrow Carson's former President and CEO Matthew Thompson. Mr. Thompson left his post Feb. 16 just 10 days after CMS threatened to revoke the hospital's Medicare funding if it didn't resolve infection control issues identified by investigators.

2. The Medicare contract termination notice was the result of a Michigan Department of Licensing and Regulatory Affairs investigation last December. The investigation was launched due to complaints filed by a nurse anesthetist Jonnie Vanderhoef, CRNA, regarding the conduct of Carson Sparrow orthopedic surgeon Raymond Allard, DO. Mr. Vanderhoef filed a against Lansing, Mich.-based Sparrow Health System on Feb. 1, alleging he was terminated after expressing concerns regarding Dr. Allard.

3. The report examines nine orthopedic surgeries performed by Dr. Allard — referenced in the report as "Staff I" — after which patients returned to the hospital with infections within 90 days. Seven of these cases were surgical site infections, though just two were documented by Sparrow Carson as hospital-acquired. The hospital's COO, Barb McQuillan, told investigators the facility examined Staff I's surgical site infection rates, but determined the surgeons patients had "multiple risk factors that placed them at higher risk than average for a post-operative infection," according to the Lansing State Journal.

4. In a statement issued Feb. 28, Sparrow Carson officials said the hospital had submitted a response to CMS that addresses areas for infection control improvement and expressed confidence the matter would be resolved "in a timely and thorough manner."

"Patient safety and quality are always a top priority at Sparrow, and we can assure our patients living in the Carson City community that they will receive excellent care," said Sparrow Carson officials, according to the Lansing State Journal.

5. One of the nine incidents documented in the report involved 59-year-old woman who had a total knee replacement at Sparrow Carson in July. She returned to the hospital multiple times to have a surgical wound drained. On the third such occasion, Staff I reportedly stitched gauze into the wound despite concerns from staff. He intended to remove the gauze the following day.

6. The incident with the gauze was also documented in a complaint filed by Mr. Vanderhoef with the Healthcare Facilities Accreditation Program.

"In recent months [Dr. Allard] has been demonstrating more and more bizarre and alarming behaviors, including intentionally leaving surgical sponges inside an infected surgical wound and closing it," wrote Mr. Vanderhoef, according to Lansing State Journal. "He was ordered to return the patient to the OR that day to remove them. It was only at the persistence of a conscientious, assertive surgical nurse that any action was taken."

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