Ben Taub Hospital violated key federal patient care and safety requirements in a case that culminated in death, according to a new report, the third such event in recent months to result in the sanctioning of a Texas Medical Center hospital.

The Centers for Medicare and Medicaid Services notified the Harris Health System of the deficiencies and moved to place it under state and federal authority in a letter and report the system received Wednesday. The action applies to all components of Harris Health, the public safety-net hospital network that operates Ben Taub.

“These deficiencies have been determined to be of such a serious nature as to substantially limit your hospital’s capacity to render adequate care,” CMS wrote in the June 26 notification letter to Harris Health.

George Masi, CEO of Harris Health, disclosed the death and CMS action in an email to hospital staff Wednesday afternoon. He wrote that the death — in the Ben Taub Emergency Center in April — stemmed “from an ineffective process in patient monitoring and communication of critical lab values.”

Harris Health did not self-report the death to CMS, which instead learned of it in a complaint. The Texas Health and Human Services Commission investigated the complaint on June 4-5 and found deficiencies in patient rights and emergency services, according to the CMS letter.

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Harris Health received the CMS letter two days after the agency released a report providing details about an MD Anderson Cancer Center patient who died after receiving contaminated blood; and a month and a half after its release of a report about a Baylor St. Luke’s ER patient who died after receiving the wrong blood type, given because of a labeling error.

The Centers for Medicare and Medicaid Services placed both those hospitals under state and federal authority after finding major deficiencies on their campuses.

The three hospitals are among the most esteemed institutions in the medical center. MD Anderson consistently ranks as the nation’s No. 1 provider of cancer care, St. Luke’s has long been regarded as a leader in heart care and the Ben Taub Emergency Center is renowned for its trauma care.

One expert warned about reading much significance into the prevalence of problems in a short period of time in the medical center, one of Houston’s most prized brands.

“What’s unusual here probably isn’t so much three hospitals in a city being involved in these sort of sanctions as it being publicly reported,” said Leah Binder, CEO of the Leapfrog Group, which grades hospitals on safety. “It’s very unusual for hospitals to self-disclose, wherever it’s coming from. They’ve never lived in the spotlight of transparency in the past.”

Binder attributed the greater transparency to President Donald Trump, whose administration’s hallmarks include holding hospitals more accountable, she said.

But CMS spokesman Bob Moos denied the agency is in any way stepping up efforts to scrutinize hospitals.

“We don’t target hospital enforcement either toward specific facilities or issues,” Moos emailed the Chronicle. “Aside from a small percentage of sample validation surveys, our oversight of accredited hospitals is primarily based on complaint investigations. Complaints can come from a variety of sources and allege a multitude of issues.”

Moos said CMS annually cites about 300 accredited hospitals for being out of compliance with the agency’s conditions of participation. When that happens, the hospital is put under state and federal authority

In his letter to staff, Masi wrote that Harris Health is working toward “a speedy resolution” of the matter.

“Harris Health’s leadership takes this matter very seriously,” Masi wrote. “Since the completion of the HHSC survey, Harris Health made substantial strides in achieving full compliance and will continue to work diligently to meet all of the applicable standards of care.”

Harris Health did not grant any interviews about the case. But in response to Chronicle questions about the death, the system cited its Emergency Services policy, which appears to have broken down. The policy refers to “an ongoing process that begins with triage and includes monitoring of the patient until qualified medical personnel determine whether an emergency medical condition exists.”

“The medical screening examination includes all services within the capabilities of Harris Health, which, in the judgment of the emergency physician or other treating or consulting physician are reasonably necessary to screen and/or stabilize an individual with an emergency medical condition,” the policy says.

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Harris Health is currently working on its plan of corrective action, said a spokesman. It has 10 days to submit its plan, after which HHSC will conduct a follow-up investigation.

Masi’s email included a link to the CMS notification letter, which became public once Harris Health received it, according to the agency. The email didn’t include a link to the full CMS report, typically not released by the agency until after the hospital submits its corrective plan.

CMS’ notification letter did not mention a death or even an “adverse event.” That was disclosed by Masi in his email to staff.

Harris Health was placed under state and federal authority as a result of CMS lifting its “deemed status,” a component of Medicare and Medicaid participation. The system will remain under government authority — instead of DNV GL Healthcare, its accrediting agency — until it demonstrates it is in compliance with CMS’ “conditions of participation.” CMS took the same action against St. Luke’s and MD Anderson.

All three remain a participant in Medicare and Medicaid programs.