King/Drew Failure Cited in 3rd Death

While the vital signs of a patient attached to a cardiac monitor declined this week, doctors and nurses at Martin Luther King Jr./Drew Medical Center apparently failed to intervene, and the patient later died, health officials said Thursday.

It appears to have been the third such death at the hospital since July. Two other patients died during the summer in the same unit after deteriorating unnoticed while attached to monitors. Those deaths led to a pair of government inspections that found serious deficiencies in patient care at the Los Angeles County hospital, and promises of internal reform.

The most recent death occurred Sunday morning. A subsequent review of the patient’s chart showed that the patient’s vital signs had changed but that no action was taken, said county health department spokesman John Wallace. The incident was reported, as required, to the state Department of Health Services, Wallace said.

The patient was discovered “in distress” about 7:30 a.m. and resuscitated, but then died about 90 minutes later, Wallace said. He did not know the cause of death, nor did he know the patient’s age or gender.

“There were some changes in vital signs that would have normally necessitated some actions on the part of doctors and nurses and there was nothing in the chart to indicate” they had responded, Wallace said. “That this happened to someone in a monitored bed is cause for concern,” he added.

The county official responsible for looking into such unusual deaths said she didn’t learn of it until Wednesday.

Laura Sarff, head of quality improvement for the county Department of Health Services, said she was troubled that she didn’t hear about it earlier from hospital or county officials. Sarff said she still had not reviewed the chart and could not comment in detail, but said the patient had been very sick with end-stage kidney or liver disease.

“We need to review this and figure out what the problems are,” she said. “It’s heightened our sensitivity because it happened on the same unit [as the other deaths]. I don’t know if this has any relationship at all to what happened over the summer.”

Last month, state inspectors said nurses and other employees had botched the care of the patients -- both women -- who died at the Willowbrook facility last summer, failing in one case to notice that a patient’s heart rate had slowed and stopped over a 45-minute period.

The inspectors also found that the nurses apparently had never been taught to use new bedside monitors displaying patients’ vital signs. And one nurse lied about performing crucial tests ordered by a doctor, the state report said.

In both women’s cases, a technician assigned to watch over a central monitor displaying the vital signs of all the unit’s patients was given other duties as well. It was unclear whether anyone was watching the monitors when the women needed emergency attention.

As a result, county officials changed the rules so that monitor technicians at King/Drew now are allowed to do nothing but watch the monitors.

Wallace said a monitoring technician was assigned to watch the central monitor last weekend. But, he said, it is unclear whether the technician was observing the vital signs of the patient who died Sunday.

“That’s going to be looked at,” Wallace said.

A nursing manager now observes the central monitor, he said. The deaths during the summer had repercussions for the hospital that extended well beyond the unit where they occurred. Inspectors found serious problems with the hospital’s nursing care, which could jeopardize crucial federal funding.

Compounding the pressure on King/Drew, the inspections also coincided with a series of negative reviews of its doctor training programs by a national accrediting organization.

What’s troubling about the latest death, Wallace said, “is that it fits into the pattern” criticized by inspectors.