Firm Monitoring King/Drew Admits Lapses in Oversight

The Los Angeles County Board of Supervisors hired Navigant Consulting Inc. last fall to ensure that lapses in patient care at Martin Luther King Jr./Drew Medical Center were caught and no longer covered up.

Now the firm acknowledges that its own staff failed to promptly investigate or report on two important patient-care lapses.

One involved an elderly patient who died March 23 after nurses allegedly didn’t respond to his bedside vital signs monitor. Navigant official Olive O’Rourke knew about the case within days but did not fully investigate it or share information with the county Department of Health Services until June, the firm’s managing director, Hank Wells, confirmed this week.

A different Navigant executive emphatically -- and repeatedly -- told the Board of Supervisors in July that her firm only found out about the incident in June. After The Times pointed out the inconsistency, Navigant Managing Director Kae Robertson sent a letter to the board Tuesday correcting her misstatement.

In the other case, a nurse allegedly fell asleep while a patient was undergoing dialysis and blood spurted from her dislodged catheter needle. A Navigant manager knew about the lapse that day, but the firm did not inform the health department, which learned of it from a tipster a week later, according to Wells and a chronology prepared by the department.

Both of the lapses in care are being reviewed by state health inspectors.

Navigant is being paid $15 million for a one-year contract to manage and stabilize the hospital. But its performance has been criticized by some county supervisors and auditors, who have questioned its success implementing its recommendations.

Wells, who is serving as King/Drew’s interim chief executive officer, said his firm erred in not reporting the events more quickly. But he said there was no deliberate attempt to cover them up.

“There have been mistakes that have been made in the way that events have been reported up, delays where they shouldn’t have happened,” Wells said. “I’m certain that those were not intentional delays. But they happened, and I can’t undo the fact that they happened.”

The Navigant employee investigating the March death was overwhelmed, Wells said, and didn’t follow through on that investigation because she was trying to fix several other problems at the hospital.

Wells said his firm and the county health department recently put in place a new process in which they talk every morning to discuss questionable cases from the day before. That appears to be working, Wells said.

Several county supervisors said Navigant’s actions raised questions about its openness. The county needs to know about patient-care lapses to prevent them from recurring and to take action against employees accused of wrongdoing, they said.

“That’s a credibility issue,” said Supervisor Don Knabe. “If in fact all that is true, they need to come forward and explain it and be upfront about it.”

Supervisor Mike Antonovich said Navigant had turned King/Drew into an “on-the-job training exercise.”

“Navigant was hired as a crisis management team. They were hired under the pretense they could do the job and would do the job without any excuses,” he said. “That appears to not be the case.”

Dr. Thomas Garthwaite, the county health director, said he believed that Navigant had learned from its mistakes and would not repeat them.

“I have no reason to believe that they’re suppressing or hiding information,” he said. “Sometimes in the middle of war, you’re not accurately counting the casualties. You turn to the next crisis, the next incoming.”

Some supervisors said they were trying to remain focused on the bigger question of King/Drew’s future, not what they see as relatively minor problems.

“If King/Drew fails, we have a huge gap in our safety net -- and that’s more important than these kinds of issues,” Supervisor Gloria Molina said.