Embattled Winnebago hospital encounters challenges, distrust

WINNEBAGO, Neb. (AP) – Last fall, Tonie Greve was experiencing severe chest pains when she arrived at Winnebago Hospital.

Greve, a member of the Omaha Tribe of Nebraska and a registered nurse who worked at the hospital run by Indian Health Service (IHS) for more than a decade, told the Sioux City Journal she had to affix the EKG leads to her chest because a nurse didn’t know how to put them on. At the time, Greve said she wasn’t sure if she was having a heart attack or just a bad bout of asthmatic bronchitis.

The first doctor she saw remarked that her blood sugar level was probably 600 milligrams per deciliter (mg/dL) because of her weight. Greve asked for her primary care doctor who happened to be walking through the emergency department.

“He goes, ‘You’re diabetic now?’ That’s how the contract doctors treat the patients,” recalled Greve, whose lab work later revealed she had a blood sugar level of 93 mg/dL. A normal blood sugar level is less than 140 mg/dL two hours after eating and less than 100 mg/dL after not eating for eight hours.

In May 2015, Greve lost her job at the embattled facility in Winnebago that provides free health care to enrolled members of the Winnebago and Omaha Indian tribes and other tri-state area tribes after she said she blew the whistle on a case of negligence that led to a patient death. That same month, the Centers for Medicare & Medicaid Services (CMS) released a report that identified a number of life-threatening deficiencies at the hospital.

CMS terminated the hospital’s Medicare contract on July 23, 2015, after IHS and hospital officials failed to correct a series of deficiencies the agency identified. More than a year later, the federal government still isn’t reimbursing the hospital for treating patients enrolled in Medicare, the federal health care program for the elderly and disabled.

IHS officials say improvements have been made at the hospital, where some top staff have been replaced and day-to-day management of the emergency department was recently turned over to a private contractor. But some tribal members say patients’ lives remain at risk.

“It’s not improving. It’s getting worse. People continue to lose their lives because of poor care,” said Wehnona Stabler, CEO of Carl T. Curtis Health Education Center, located on the Omaha reservation in Macy. Stabler was employed with IHS for 31 years.

Tori Kitcheyan, treasurer for the Winnebago Tribe, testified before the Senate Committee on Indian Affairs in February. She said at least five of the hospital’s patients have died “unnecessarily,” including a child under age 3. These deaths were documented in CMS reports.

In July, Kitcheyan told the House Subcommittee on Indian, Insular and Alaska Native Affairs, “We have no way of knowing how many more unnecessary deaths and misdiagnosis have occurred at the hands of IHS personnel.”

In a statement last week, Kitcheyan told the Journal the tribe remains hopeful the hospital will be ready for Medicare recertification this fall, but she said the Winnebago Tribal Council continues to receive complaints about administrators, providers and poor quality of care at the hospital.

Stabler and Greve both cited the March death of a patient with diabetes. They say the unidentified woman died because medical staff at Winnebago Hospital’s emergency department failed to perform a finger-stick test to check her blood sugar.

The Journal contacted CMS to try to verify the allegation. CMS doesn’t have the authority to conduct investigations because the hospital isn’t currently a Medicare-certified facility, according to a CMS spokeswoman.

IHS spokeswoman Britt Ehrhardt wrote in an Aug. 9 email that IHS is unable to comment on specific cases due to medical privacy laws.

She wrote that IHS is working with the Winnebago and Omaha tribes to implement a comprehensive plan to ensure the safe delivery of care for all patients at the hospital and to restore full Medicare billing and reimbursement work.

Under its treaty rights, Kitcheyan said the tribe is working to compact with IHS to assume full funding and control over programs, services, functions and activities that IHS provides.

“The Winnebago Tribal Council is committed to a successful transition while ensuring the health, safety and wellness of the 10,000 Native Americans who count on the facility for health care,” she said.

In exchange for ceding millions of acres of tribal lands, American Indian tribes are guaranteed federal responsibilities and benefits, including free health care, through treaties made with the federal government.

IHS, an agency within the Department of Health and Human Services, is responsible for providing federal health services to 1.9 million American Indians and Alaska Natives who belong to 567 federally recognized tribes in 35 states. It was established in 1955 after American Indian health services were transferred from the Bureau of Indian Affairs to the Public Health Service, in hopes of improving the health care of American Indians living on reservations.

Mark Morgan, a primary care physician who served as acting clinical director at Winnebago Hospital from June 2012 to October 2014, said diabetes is prevalent among patients who live on the Omaha and Winnebago reservations.

He said additional conditions that occur along with diabetes include heart disease, infections, amputations and kidney disease. Autoimmune diseases such as rheumatoid arthritis and scleroderma also disproportionately affect American Indians, according to Morgan.

“Patients really suffer from all of these complications that go along with diabetes and the onset is very young,” said Morgan, who now works as clinical director of Carl T. Curtis Health Education Center. “In our nursing home we have people in the 40-year-old age range.”

Stabler said some members of the Omaha Tribe are afraid to go to Winnebago Hospital’s ER just 9 miles up the road.

According to a May 2015 CMS survey, the hospital caused “immediate jeopardy” to 10 of 30 randomly selected patients. Those patients include a 60-year-old man came to the hospital multiple times on July 3, 2014, complaining of chest pain. A physician never examined the patient, who was tearful and grabbing his chest. He was eventually transferred to a Sioux City hospital.

There is also a 28-year-old woman, who was 14 weeks pregnant and experiencing bleeding, arrived at the hospital on April 12, 2015. When staff couldn’t find a fetal heart beat with equipment, they told the woman’s mother to drive her to a Sioux City hospital.

Another randomly selected patient is a 15-month-old with rapid breathing and a fever was discharged on Jan. 20, 2015, after receiving a nebulizer treatment and ibuprofen. The child’s parents brought him back on Jan. 22 in respiratory distress. The child was transferred to a Sioux City hospital.

Stabler said she has given gas vouchers to patients who want to seek medical care elsewhere. The majority of people living on the reservation, she said, can’t afford care at the next closest hospitals in Sioux City, Omaha or Pender, Nebraska.

“The law asks you to go there. They want us to go there first,” Stabler said. “Because that hospital’s not functioning, because we cannot depend on it, because a lot of us are scared to go there, it has created a whole other level of burden and that’s not fair to the patients.”

Emergency department encounters declined at Winnebago Hospital from fiscal year 2014 to fiscal year 2015, falling from 10,496 to 9,564, according to IHS data. The facility recorded 10,379 emergency department encounters in fiscal year 2013. However, the hospital’s average daily patient load increased from 2.1 in 2012 to 9.2 in 2014.

In May, the IHS contracted with AB Staffing Solutions to take over emergency departments at Winnebago and two other troubled IHS hospitals on the reservations of the Pine Ridge and Rosebud tribes in South Dakota.

AB Staffing Solutions will manage the three hospitals for a year, with an option for an additional four, one-year contracts. If the company stays for six years, the contract would be worth $60 million.

In July, AB Staffing Solutions personnel began running the Winnebago Hospital’s emergency department, which is fully staffed with a director, four physicians and two mid-level providers. A physician is at the hospital 24 hours each day, Ehrhardt said in an email.

The Winnebago Hospital also was included in a national contract to provide hospital management staff with intensive training and education on the Centers for Medicare & Medicaid Conditions of Participation for Medicare, she noted.

Evan Burks, president of the Gilbert, Arizona-based company, acknowledged AB Staffing Solutions “has much work to do,” but he said the quality of services will continue to improve by working with IHS staff and the community. He said board certified or board eligible emergency physicians are providing care at the hospital.

“I’m proud of our staff for accepting the challenge of attracting qualified, quality personnel, especially at a time when emergency department experienced providers and RNs are in high demand throughout the nation,” he said.

Serious management problems and substandard health care services at tribal hospitals in the IHS’ Great Plains region based in Amberdeen, South Dakota, first came to light in 2010 when former U.S. Sen. Byron Dorgan, D-North Dakota, launched an investigation into the facilities.

The Dorgan Report found several IHS facilities had health care providers on staff who lacked proper licensing or credentialing. Staff positions at these facilities remained vacant for long periods of time and service units experienced substantial and recurring diversions of reduced health care services due to a lack of qualified providers or funds.

The report also revealed employees with a record of misconduct or poor performance were being transferred to different health facilities within the IHS system.

Greve said some changes were made in 2011, but within two years of the release of the investigation’s findings, she said “proactive solutions” were replaced by “silence.”

In 2013, she said she started noticing staff at Winnebago Hospital weren’t complying with federal health care system regulations by working outside their scope of practice.

A pharmacist was examining wound care patients and writing orders, while nurses were mixing intravenous medications and running laboratory equipment, according to Greve. She said she was asked by a supervisor to go to the drug dependency unit to write orders and dispense medications to patients. She said she refused because she lacked training in that area.

Greve said nurses were carrying out doctor’s orders that had been discontinued or were no longer valid.

While patients who came to the hospital seeking emergency contraceptives or drugs to treat sexually transmitted diseases were being sent home without medication, Greve said some patients with wounds were taking antibiotics longer than they should have been. The overuse and misuse of antibiotics contributes to antibiotic resistance, a growing public health concern that makes it harder and more expensive to treat bacterial infections.

Greve said her brother’s recovery was delayed when staff failed to renew a medication he was prescribed to treat a wound. She said family members who use Winnebago Hospital continue to tell her they aren’t getting their medications.

The death of a patient on April 17, 2014, put Winnebago Hospital and IHS back under the microscope.

Greve, who was working when the patient went into cardiac arrest, reported the wrongdoing she witnessed, prompting CMS to review the facility.

According to CMS’s survey, a 35-year-old man was admitted to the hospital with breathing problems on April 14, 2014. Over the next three days, nursing staff failed to measure his oxygen intake and output and report his deteriorating condition to the attending physician.

At 10 a.m. on April 17, the man was found on the floor of his room. Ten hospital personnel, including a physician, spent 30 minutes getting him back into bed. The hospital didn’t have mechanical lifting equipment that could accommodate the 590-pound patient.

At 12:40 p.m., the patient’s blood pressure dropped significantly and he stopped breathing.

The charge nurse didn’t know how to access the hospital intercom system from the telephone in the patient’s room to call an emergency alert, according to the survey. Twenty more minutes elapsed before the patient was intubated because the crash cart was missing emergency airway resuscitating equipment. The man later died.

“I had told everybody that day, ‘I am blowing the whistle,”’ recalled Greve, who now lives in Mesa, Arizona.

After moving, Greve gave up nursing for a while. She said she still has nightmares about the man’s death.

“That’s the thing that really hurts me. Gosh, if I’m ever hospitalized and I go critical, am I gonna die?” she said.

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Information from: Sioux City Journal, http://www.siouxcityjournal.com