Suspension of Nurse at Edgemoor Is Lifted by Civil Service Board

The San Diego County Civil Service Commission on Wednesday overturned the eight-week suspension of an Edgemoor Geriatric Hospital supervising nurse who was disciplined after a patient in one of her wards drowned in a bathtub while unattended.

The commission said Department of Health Services Director James Forde was wrong to charge nurse Gertrude Shaw with trying to cover up the facts surrounding the Dec. 10 death of Josephine Noonan.

A report written by Commissioner Darlee Crockett, who presided over Shaw’s appeal hearing, called the 40-day suspension “unnecessary, unreasonable and disproportionate.”

The commission found Shaw not guilty of four of the five charges Forde leveled against her, and said her actions in failing to fully complete a report on the drowning --the basis for the fifth charge --were “understandable” because the hospital was short-staffed and Shaw dealt with two other emergencies that day.

Instead of a suspension, the commission ordered that Shaw be given a letter of reprimand for her failure to add proper information to the incident report.

“I’m relieved,” Shaw said when reached at Edgemoor, where she continues to work. Shaw, who never spoke to the press while her suspension was being appealed, said she didn’t “really know” why she was so severely punished by the department.

“When you’ve been involved in nursing since you were 16 and you’ve tried to do your best and never gotten in any trouble and all of a sudden the whole world is falling down around you, it’s hard to get beyond that and see why,” Shaw said.

Shaw’s union representative, Pat Vetere, argued throughout the eight-day hearing that the nurse was being used as a scapegoat by the Health Services Department for Edgemoor’s many problems, most of which have since been attributed to shoddy management.

Shaw was the supervisor in charge of nurses’ assistant Alverta (Pearl) Martin the day Martin left Noonan, who was partially paralyzed, alone in a bathtub while she searched for a comb. When Martin returned, Noonan’s head was tilted back and her eyes and nose, but not her mouth, were covered by water. She was not breathing.

Noonan, 66, was pulled from the tub and resuscitation efforts begun, but she was pronounced dead a short time later at Grossmont Hospital.

Martin filled out a report on the death but failed to mention that she had left Noonan alone in the tub. Martin left Edgemoor that day and never returned to work. Shaw reviewed the report and added the words “Pt’s (patients) should not be left in the tub unattended.”

Two months later, as the public and the county Board of Supervisors grew increasingly restless over repeated reports of problems at Edgemoor, Shaw was suspended for 40 working days.

In addition to failing to correct Martin’s report, Shaw was charged with failing to properly inform emergency medical workers who tried to revive Noonan, with failing to correct Martin’s version of Noonan’s medical chart, with repeatedly allowing patients to be left unattended, and with knowingly allowing patients, including Noonan, to go extended periods without proper baths.

At Shaw’s hearing, the department presented little evidence to support its charges against her. Vetere, meanwhile, called witnesses who testified that Shaw was a model supervisor who knew state and hospital regulations and followed them strictly.

Shaw also testified that, rather than covering up the drowning, as Forde alleged, she had written a detailed account of the morning’s events two weeks after Noonan’s death at the request of the County Counsel’s office.

In overturning the suspension, Crockett said “very little harm” resulted from Shaw’s failure to add relevant details to the incident report.

Forde maintained Wednesday that Shaw was not singled out unfairly.

“It was not the department’s intent to make her a scapegoat,” Forde said. “We felt the discipline was appropriate, and the commission felt otherwise. We will abide by their decision.”

In addition to its order overturning Shaw’s suspension, the commission sent Forde a letter that Crockett said dealt with other issues raised during Shaw’s hearing but not directly relevant to her case.

Among the issues was the testimony of Martin, the nurses assistant who left Noonan alone in the bathtub before she drowned. Martin said that Paul Simms, deputy health services director, had offered her money to compile a report on Edgemoor and that she had written the report but never received the money.

“The question of the source of the funds to pay Mrs. Martin was never established (whether they were to come out of Mr. Simms’ pocket or county funds),” Crockett wrote. “In either case, payments of this nature have the appearance of impropriety, and I’m sure you would want to correct any misconceptions that arose in the public hearing.”

Forde said Simms told him he “did not recall” offering Martin money for the report, but the health director said he plans to investigate.

“I do think I need to look into it a little further,” Forde said. “If the Civil Service Commission is raising this as an issue, I want to make sure I follow up on it and all the bases are covered.”