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Another Fatal Failure at King/Drew

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Another patient hooked up to a cardiac monitor died at Martin Luther King Jr./Drew Medical Center recently after nurses failed to notice the patient's deteriorating vital signs, Los Angeles County health officials reported in a confidential memo late Monday.

The death last month is the sixth case in 21 months in which a critically ill patient at the county-owned hospital was virtually ignored while monitors designed to alert nurses to trouble went unheeded.

After each case, county officials promised to retrain nurses and emphasize the importance of watching patients' vital signs.

The continued problems at King/Drew are expected to dominate today's scheduled meeting of the county Board of Supervisors.

The health department's memo to the supervisors also reported a second death after lapses in patient care. It offered a terse description of the cardiac-monitor case.

The patient's monitor noted a drop in blood pressure, but "nursing took no action," health officials wrote.

"Approximately an hour later, the monitor began to sound that the patient's heart rate was getting dangerously low. The nurses assigned to the patient did not take any action and claimed that they did not hear an alarm."

Thirty minutes later, a charge nurse noticed the poor vital signs on the monitor. A Code Blue was called, but the patient was pronounced brain dead 35 hours later, the memo said.

Hospital technicians and the monitor's manufacturer both inspected the machine and found it to be "in proper working order," the memo said.

The health department told supervisors that it investigated the death and other incidents after The Times inquired about them.

The latest report left county supervisors struggling to find a response.

"This is a regurgitation of what happened last year," Supervisor Gloria Molina said. "The same thing. I don't understand what it takes, or what it means, or how you can have such callous persons in a hospital who are supposed to be listening to a monitor.

"Our liability is growing every single day," she said.

Supervisor Mike Antonovich said the board needs to act aggressively before more patients die.

"It's time to take action," he said.

Supervisor Zev Yaroslavsky said the latest batch of problems would probably force him and his colleagues to reopen the question of whether the hospital can continue to operate.

"There's not going to be a pretty solution to this," he said. "This is a terribly ugly situation."

Today, the supervisors are expected to debate a motion by Antonovich to reconsider the county's ties with Charles R. Drew University of Medicine and Science, which oversees the training of aspiring specialists at King/Drew. The lax supervision of doctor trainees was cited in virtually all of the recent cases of patient-care lapses at the hospital, which is in Willowbrook just south of Watts.

Monday's memo was the second in two weeks in which the county Department of Health Services has told the five supervisors about fatal breakdowns in care. Just last week, officials provided details about three deaths over a four-day period in late March after what officials believed were critical medical lapses.

Health department officials had refused to release a copy of the latest memo. Supervisors commented on it after the contents of the report were read to Times reporters.

All of the new incidents have happened on the watch of Navigant Consulting Inc., the outside firm hired in November to take over operations at King/Drew. Navigant is being paid $13.2 million for its yearlong contract.

Beyond the distressing details of the latest mistakes, Molina said she is frustrated that the health department had to learn of the lapses from The Times and not from Navigant.

"To me, [Navigant officials] were my saviors. They were going to be the ones to come in and put in place standards at all levels of the organization," Molina said. "If they're not even catching these big errors, then who am I supposed to trust?"

In the other cases outlined in Monday's memo, health officials found that King/Drew emergency room staff in January had incorrectly classified a patient with chest pressure and kidney pain as non-urgent. After 4½ hours with little treatment, the patient left the ER, only to return several hours later with elevated blood pressure and chest pain.

The patient became unresponsive a short time later and died of an aneurysm, the memo said.

In a third case, King/Drew staff did not perform a full set of X-rays on a paraplegic patient hit by a car in January. The patient was diagnosed with a broken leg three days later when he sought care at Rancho Los Amigos National Rehabilitation Center in Downey, the memo said.

Dr. Thomas Garthwaite, director of the county Department of Health Services, did not return repeated calls seeking comment on the cases.

King/Drew's pattern of monitor deaths goes back at least to the summer of 2003, when two women deteriorated unnoticed.

Those deaths led to two government inspections that found serious deficiencies in patient care.

In December 2003, another patient died under similar circumstances.

Then, last fall, two patients died within six weeks when nobody noticed their deteriorating condition.

On Oct. 7, for instance, a nurse silenced the alarm on the vital signs monitor of a 28-year-old man, then failed to notice that his heartbeat was fading, according to county officials and the nurse's suspension letter. Officials allege that the nurse falsified the man's medical chart.

A second patient, a 47-year-old woman, died Nov. 18 after a nurse ignored her deteriorating condition over the course of a day, neglecting to alert doctors until the woman was in cardiac arrest, health officials said.

The nurse, an 18-year veteran, also allegedly falsified documents to indicate that she had checked the woman's vital signs when she hadn't, health officials said. After the woman died, the nurse was accused of getting the patient's file and adding notes about the woman's final hour, then lying about doing so, health officials said.

After the November 2004 death, Yaroslavsky asked Los Angeles County Dist. Atty. Steve Cooley to investigate.

The district attorney's office still is reviewing the cases, but has taken no formal action, officials said.

On Monday, Yaroslavsky renewed his call, saying that some King/Drew nurses don't seem to be getting the message. He said he didn't know all the details of the latest monitor case, but he found the fact that another patient's failing condition went unnoticed was "mind-boggling."

"The consequences of doing something like this are criminal," he said. "Obviously they didn't feel that jeopardy.

"You prosecute politicians that are corrupt," he said. "You ought to prosecute medical personnel that are corrupt."

Copyright © 2014, Los Angeles Times
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