State Report Faults Riverside Hospital in 2 Patient Deaths

Serious deficiencies in emergency services, staff and management at Riverside Community Hospital contributed to the deaths of two patients within a one-month span, according to findings by state and federal regulators.

A 52-year-old man who had been in a car accident died Dec. 22 from internal bleeding after the hospital failed to promptly locate a surgeon or angiography specialists. In January, a 36-year-old woman died in the operating room after her surgeon was called to an emergency in San Bernardino.

The state Department of Health Services, on behalf of the U.S. Department of Health and Human Services, investigated the deaths after a complaint was filed.

“The cumulative effect of these systemic problems resulted in the facility’s inability to ensure the provision of quality health care in a safe environment,” the report says.

Since the findings were made, the hospital has submitted a correction plan to the Department of Health and Human Services and is implementing it, said Steven Chickering, a San Francisco-based manager for the U.S. Centers for Medicare and Medicaid Services, an arm of the federal agency.

“They failed to ensure that the systems in place were adequate to meet the needs of the patients,” he said.

A hospital spokeswoman did not return calls Wednesday.

The correction plan includes outside review, new scheduling policies, monitoring of cardiovascular cases, education efforts and other components, according to the report.

The man, whose name was not released, was admitted to the emergency room at 8:50 p.m. Dec. 21 after a traffic accident. Tests were performed over a four-hour period, indicating a possible ruptured aorta, according to the report.

An angiogram, which details the condition of the heart and blood vessels, was ordered and the staff tried to find a cardiovascular surgeon. Three were unavailable or did not respond to pages; a fourth agreed to operate. But there were delays in finding qualified personnel to conduct the angiography.

Shortly before 4 a.m., a team was ready, but within minutes, the patient was unresponsive and no longer had a pulse, according to the report.

After he was resuscitated, the angiography team said he was too unstable for the test. The surgeon refused to operate because of the increased risk of death. Another surgeon was called and evaluated the patient about 7 a.m. He refused to operate because the patient had bled through the night.

An order not to resuscitate the patient was written, according to the report. He died that afternoon, more than 17 hours after he arrived.

The woman, who had had an aortic valve replacement seven years earlier, arrived at 6 a.m. Jan. 18, complaining of chest pain. Testing revealed an aortic rupture and blood in the chest, according to the report.

The woman, whose name was also withheld, was prepared for surgery just before 11 a.m. But then it was realized that the surgeon had been called to a patient in San Bernardino, about 15 miles away.

The woman lost consciousness at 11:44 a.m. Staff began CPR and paged the surgeon. He told them that their resuscitation efforts were futile. The patient died shortly after CPR was discontinued, the report says.

“We would expect that the medical staff is organized in such a way that ... the physicians responsible for providing care will do so competently and [in a timely manner], in accordance with patient needs,” Chickering said. “There were examples where that didn’t happen.”

Riverside Community Hospital, part of the HCA Healthcare system, has 364 beds and 400 physicians. It opened in 1901. The hospital’s specialties include emergency and cardiac care, according to its website.

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A medical staff’s decisions and actions during a patient’s last hours

A federal and state investigation of two recent patient deaths at Riverside Community Hospital revealed staffing and emergency service deficiencies. A look at one of the cases:

8:50 p.m. On Dec. 21, 2003, a 52-year-old with multiple traumas is admitted to emergency room following a traffic accident. Initial chest X-ray is ordered 15 minutes later.

9:46 p.m. Initial chest X-ray is performed and read by ER physician and trauma surgeon.

10:15 p.m. A Computerized Axial Tomography (CT) scan is ordered.

12:33 a.m. CT scan is performed and read by tele-radiologist.

1:55 a.m. A preliminary report is dictated and authenticated. The findings indicate a possible ruptured aorta. The tele-radiologist phones ER physician with findings and concerns.

2:45 a.m. Trauma surgeon orders angiogram after notification of CT results.

Between 2:45 and 3:15 a.m. Attempts to consult with a cardiovascular surgeon (CV): CV #1: Paged CV #2: Returned page. Already started another case in operating room. CV #3: Paged. No response. CV #4: Available via phone. Informed that patient had aortic rupture. Requested angiogram. Attempts to contact an on-call radiologist: Radiologist #1: Contacted. Stated he was not qualified to perform procedure. Radiologist #2: Contacted. Stated he was not on call and that radiologist #3 was covering for him.

About 3:15 a.m. Radiologist #3 arrives at facility. Phones CV #4 and informs him that angiogram is not indicated since the injury is “behind the curve” and the test would be useless. CV #4 continues to state he needs angiogram before surgery.

3:30 to 3:49 a.m. Angiography registered nurse, angiography technologist, X-ray technician for the angiography team arrive.

3:55 a.m. Patient is anxious and complains to family of hyperventilation. Five minutes later is unresponsive and has no pulse. CPR is initiated.

Between 4 and 6:11 a.m. The angiography team feels that at this point the patient is too unstable to go to angioplasty suite. Radiologist #3 reconstructs the CT films. He phones CV #4 and discusses the level of the aortic injury. After the patient is resuscitated, CV #4 refuses care of the patient because of the increased risk of death related to surgery.

6:11 a.m. Trauma surgeon calls CV #3 to consult on patient.

6:55 a.m. CV #3 evaluates and determines condition is inoperable because of “lung contusions” and probable bleeding through the night.

8:05 a.m. A “No CPR” order is written. Patient is then given supportive care and comfort measures. Patient dies about 6 1/2 hours later because of “...injury of aortic rupture...”.

Source: California Department of Health Services