WORCESTER – Staff at St. Vincent Hospital did not follow proper patient identification procedures in a July 20, 2016, surgery that resulted in a healthy kidney being removed from a patient, according to a report released by a federal agency Thursday about the error.

The mistake has resulted in the hospital being placed on notice that its Medicare and Medicaid agreement will be terminated Dec. 12. The hospital has been told it can avert the termination if it corrects deficiencies found by regulators.

The report of an investigation the state Department of Public Health’s Division of Health Care Facility Licensure conducted at the hospital in late August concluded that the facility “was not in substantial compliance” with the requirements for patient’s rights, quality assessment and performance improvement, medical record services and surgical services.

DPH conducted the unannounced on-site investigation in conjunction with the federal Centers for Medicare and Medicaid Services.

“The Department expects the hospital to take immediate steps to address the findings of the investigation and will continue to monitor ... through unannounced inspections,” DPH Spokesman Tom Lyons said via email Thursday.

Asked Thursday whether St. Vincent would have the deficiencies corrected by the Dec. 12 deadline, hospital spokeswoman Erica Noonan responded in an email: "We are working to implement enhanced safeguards as identified in the CMS survey, including additional verification steps with physicians," she said. "This was a deeply unfortunate situation and we will take all steps necessary to prevent it from happening again."

According to the 32-page report, on July 20, the patient was at St. Vincent to have the left kidney removed because of a large tumor.

During the surgery, it was determined that the patient’s kidney did not have a tumor. The kidney was sent to the Pathology Department which notified the surgeon that the kidney did not have a tumor.

“It was later determined that (the patient’s) admission and plan for surgery to remove the tumorous kidney was based on another patient’s Computerized Tomography (CT) scan results, in error,” the report read.

The Operative report revealed that there were two patients with the same name who had CT scans at another hospital on the same day in June and their birth dates were a few years apart.

After the error was publicized in August, Ms. Noonan said in a statement that the patient's outside physician misidentified the procedure the patient needed before he was brought to St. Vincent. The patient's physician scheduled the surgery at St. Vincent Hospital.

The internal investigation done by the hospital determined that the medical record of the patient who was mistakenly operated on did not contain a CT scan report, one of the methods the hospital uses to confirm a patient’s diagnosis, the investigation found.

Nurse practitioners, who are responsible for the assessment of the patient’s condition and needs, who were interviewed, said the pre-admission testing unit did not always receive reports and physician notes prior to their assessment of the patient before surgery.

Mr. Lyons, the DPH spokesman, declined to say if the patient whose kidney was removed by mistake received another kidney.

Subsequent to the surgical error, the hospital failed to take appropriate action to prevent a recurrence, according to the report.

To correct that, the hospital plans to have “all surgical cases which are deemed clinically necessary based on an imaging study, have the images available, present (displayed) prior to the surgery to verify the patient’s name, date of birth, surgical site and side..."

Among a host of other corrective actions, the hospital is required to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program.

During their investigation of the kidney surgical error, surveyors also found problems in some of the other 19 sample records they looked at.

In late June, the hospital put an identification bracelet on a patient’s son instead of the patient. The hospital report indicated that there was a language barrier. However, the hospital’s report did not indicate if the hospital conducted an investigation of how the error happened and if an interpreter was used.

According to a July 11 hospital report, a radiology technician saw a patient without an identification bracelet. The technician called the patient care unit to bring the band down. The report failed to indicate any follow-up regarding the incident.

Another report in August indicated a patient registered with another patient's name. The report said the hospital corrected the patient's registration and the issue was resolved. The report indicated that the patient had two medical record numbers. But the hospital report did not indicate: if the other patient existed in the electronic medical record system, if the hospital treated the patient as the other patient and if the hospital corrected the other patient's electronic medical record.

During the investigation regarding the wrongful kidney removal, surveyors were told that the patient's medical record number was corrected.