State Cites Edgemoor for Laxity, Will Assess Fine

Citing a poor track record, carelessness and a serious procedural lapse, state investigators assessed the maximum penalty Monday against county-run Edgemoor Geriatric Hospital in connection with the death of a 93-year-old patient who was accidentally fed through her windpipe.

The 323-bed hospital, which houses elderly, handicapped and mentally ill patients with nowhere else to turn, was charged with direct responsibility in the death of Lorna Doone Bone, who died at the Santee hospital Jan. 9, several hours after a feeding tube was administered incorrectly.

The county, which can appeal the finding, could be fined as much as $25,000.

The highly critical report by the state Department of Health Services, handed to county officials Monday, said the nurse who made the mistake had not performed a nasal tube feeding for more than four years.

She “was not familiar” with the equipment being used and took none of the proper precautions to ensure that it had been properly administered, the report added.

When Bone later started coughing and breathing heavily, neither the nurse nor two nurses’ assistants recognized those as distress symptoms.

The report did not identify any of the hospital personnel by name.

Bone, suffering from a respiratory ailment, was terminally ill at the time of the accident.

But Ernest Trujillo of the state Department of Health Services said investigators believed that they should “not make a difference” in determining the severity of the citation against the hospital. The citation issued Monday was for the most severe administrative penalty allowed for substandard care by health care facilities.

The citation is a setback for county officials trying to improve the image and turn around the management of the much-maligned facility. It also made for a rude first-day welcome for Florence L. McCarthy, who took charge of Edgemoor on Monday.

Hospital and county health officials huddled among themselves after receiving the report, then refused to answer press inquiries.

“We’ve gone through some bad times, so they decided any comments to the press would have to come through (county press spokesman) Bob Lerner,” Edgemoor manager Mary Wade said late Monday.

Lerner could not be reached for comment, and there was no indication given on whether the county will appeal the citation. But last week--before the state report had been completed--acting administrator Paul Simms said proper procedures had been followed by hospital personnel.

In a handwritten “plan of correction” given state officials Monday, Edgemoor’s associate administrator, Robert Parsons, wrote that the hospital will see that nurses get continuing training on how to use feeding tubes and how to recognize distress symptoms.

“This program will be directed specifically to licensed nurses who have not performed this particular procedure during the last 12 months,” the document said.

Under procedures applicable in such cases, the county could satisfy the citation by paying $12,500--half the maximum fine--within five days and submitting a plan to assure that there are no similar accidents in the future.

Otherwise, the county could appeal to an administrative review panel, and subsequently to a Superior Court judge. Or, it could ask for arbitration before an administrative law judge, whose ruling would be final.

The hospital, in Santee, has been the target of numerous governmental investigations in recent years. Since May, 1984, Edgemoor has been assessed fines totaling $43,500--not counting Monday’s citation--for violations that have included improperly administering drugs, using unwarranted restraints and being inattentive to invalids and amputees. In May, the federal government threatened to withhold $8 million in Medicare and Medi-Cal funds.

But county and state officials launched a program last year to upgrade patient care with infusions of money, a bigger staff and remodeling.

Republican Assemblyman Larry Stirling of San Diego, whose criticisms triggered much of the governmental attention, said Monday that Bone’s death and the manner in which it occurred is saddening. But he added that it is counterproductive for the state to levy heavy fines against the troubled hospital.

“That’s $25,000 less that they have to do their job,” Stirling said.

Stirling said county officials have made significant improvements at Edgemoor since he started complaining about conditions there and called for a state audit.

“I’m certain they’ll take corrective action in this regrettable incident,” Stirling said.