State to Study Drug Death at FHP Hospital

State health authorities are opening an investigation into the case of an elderly cancer patient who died at FHP Hospital in Fountain Valley because of a nurse’s mistaken infusion of the wrong drug, an official said Friday.

The Times also learned on Friday that the nurse who allegedly made the medication error, 37-year-old Maureen Daubert, is working at a VA hospital in Lebanon, Pa.

In a brief telephone interview, Daubert, a registered nurse, expressed shock that details about the incident had become public. She declined to comment.

The investigation is being handled by the state Department of Health Services, which has jurisdiction over the licensing of California hospitals. Jacqueline A. Lincer, the health department’s licensing administrator in Santa Ana, said she had assigned an investigator to review FHP records and “procedures” concerning the care of 74-year-old Francis J. Johnson.

“This is a horrendous thing that happened, this medication error,” Lincer said. “But it does on occasion happen.”

Also Friday, Van Nuys attorney John L. Moriarity, who represents Johnson’s family, said he will probably file suit against the hospital to gain access to hospital records.

Hospital officials have confirmed that Johnson died last Nov. 14 after Daubert accidentally injected her with potassium chloride instead of following a doctor’s written order to administer the diuretic Lasix.

Told of the state investigation, FHP associate vice president Anna Marie Dunlap said, “That doesn’t surprise me.” After press reports of the death this week, “I think they would feel obligated” to investigate, she said.

FHP issued a statement Thursday calling the nurse’s action “an inexcusable lapse in judgment” and saying the hospital was cooperating fully with investigators.

“The nurse’s unfortunate mistake is not in any way indicative of the general quality of care offered at FHP’s hospital,” the statement said. It added that FHP was conducting its own investigation.

Nurse Daubert has been on staff at the Veterans Administration Medical Center in Lebanon, Pa., since May 7, hospital spokesman Steve Gallerizzo confirmed. He said the hospital checked Daubert’s credentials and was told “there were no impairments” to her California nursing license.

In addition, an Anaheim nursing registry rated Daubert’s performance from July, 1988, through this April as “superior,” and the nursing director at FHP reported that Daubert had left their employment “voluntarily,” Gallerizzo said.

He said the FHP nursing director reported Daubert’s dates of employment but “did not fill out the performance data” that the VA’s reference form requested.

FHP officials reiterated Friday that Daubert was fired last November--seven days after Johnson’s death--because she made an “egregious error,” allegedly grabbing the wrong medication from a shelf and injecting Johnson with it.

Still, Dunlap said, “in keeping with the laws governing employee rights to privacy,” the hospital may not have told a potential employer that Daubert was fired but rather only “confirmed the name, dates of employment and position the employee held.”

Johnson suffered cardiac arrest and died 40 minutes after the wrong medicine was administered, deputy coroner Bruce Lyle has said.

Although FHP physician Dr. Sabry Ghaly signed a Nov. 15 death certificate attributing Johnson’s demise to “metastatic breast cancer,” the coroner’s office on Thursday formally amended that document, saying the cause of Johnson’s death was “acute potassium intoxication.”

In its Thursday statement, FHP said its own investigation had found it difficult to determine Johnson’s exact cause of death because “any one of several acute problems could have been at fault, including septic shock, massive heart failure and terminal cancer beyond treatment.”

Fountain Valley police inspector Steven J. Williams has been investigating circumstances surrounding the death. He said Friday that he plans to question FHP doctors and nurses involved in treating Johnson next week and plans to present his findings to the district attorney’s office later this month.

In addition, an official at the California Board of Registered Nursing has confirmed that Daubert has been under investigation since January. She said a recommendation could be submitted to the attorney general’s office for civil action within a month.

But for now, Daubert’s “license is still clear” because no formal accusation has been filed against her, said Susan Brank, the board’s assistant executive officer.

Brank noted that any hospital checking on Daubert’s background would probably not be told that she was under investigation. “It would not become public information until the complaint was substantiated,” Brank said.

Details of Daubert’s background remained sketchy Friday. But Brank said Daubert has held an active, and unblemished, registered nursing license in California since September, 1981.

Before that, she was licensed as a registered nurse in Massachusetts from 1980-1984, where she earned her nursing degree from Springfield Technical Community College in 1980. No complaints were on file against her there, a spokeswoman for that state’s nursing board said.

Although Daubert does not appear to hold a nursing license in Pennsylvania, federal law does not require that, said VA spokeswoman Donna St. John. She said federal law only requires that a VA nurse hold a nursing license from any state.

Commenting further on the state health department’s investigation, licensing chief Lincer said her agency is not empowered to impose fines on a hospital or its owner, but could, in an extreme situation, suspend or revoke a facility’s license to operate.