Barstow Veterans Home Fined $95,000 Over Death

A top state health official has levied a $95,000 fine against the struggling California Veterans Home at Barstow in the December death of a World War II combat hero who was given conflicting medications but whose doctors failed to recognize that he was worsening until it was too late.

Health Services Director Diana Bonta announced the fine this week after an investigation into the death of Billy D. McGowen, 78, a resident of the state-operated nursing home. He died Dec. 4 of heart failure resulting from the toxic interaction of two high-powered medications, she said.

The fine, $5,000 short of the maximum $100,000 penalty, was the first levied since June 2000, when Bonta fined the Barstow facility $64,499 in the deaths of one veteran who choked on his broccoli lunch and another whose diabetes was not properly monitored for weeks.

Before the latest incident, Davis administration officials had said they were hopeful that the troubled Barstow home had turned around after a long history of failing to properly care for patients.

At one point, the Health Department -- a sister agency of the state Department of Veterans Affairs, which operates three veterans homes -- closed the Barstow nursing facility to new patients while it investigated what it found to be low-quality care of patients. At another point, the federal government withdrew payment of Medicare funds until the facility had demonstrated improvement of its operations.

The controversies have been an embarrassment for Gov. Gray Davis, an Army veteran who had described himself as the “best friend” of California veterans and insisted that the dignity and care of former members of the military was at the top of his priority list.

In December, Davis appointed retired state Sen. Maurice K. Johannessen, a Redding Republican, as secretary of the veterans department with orders to ensure that the nursing homes in Barstow, Chula Vista and Yountville were operated as world-class operations.

McGowen was an Army combat veteran of Europe who, according to his son, Jim, was awarded two Bronze Stars and a Purple Heart. In a report Monday, Bonta said McGowen was returned to the veterans home on Nov. 4 from Barstow Community Hospital, where he had been treated for an irregular heartbeat. A community hospital physician prescribed the medication amiodarone for his condition.

But upon McGowen’s readmission to the veterans home, Bonta said, a staff physician added the drug digoxin to his list of medicines. She said that digoxin mingled with amiodarone caused a toxic reaction, with symptoms including loss of appetite and weight.

Over the next few weeks, McGowen’s condition weakened dramatically and his blood pressure fell. On Dec. 4, Bonta said, McGowen was taken to the emergency room of a Barstow medical center, where he suffered heart failure and died within an hour.

The coroner listed McGowen’s cause of death as heart failure due to the toxicity of digoxin.

Bonta also said the staff of the nursing home failed to properly monitor McGowen’s medications and did not recognize the symptoms of digoxin toxicity until he got to a point from which “he could not be revived.”

The two staff physicians of the veterans home have been suspended from caring for patients, the veterans department said, pending the outcome of an internal investigation. A spokesman refused to disclose their names.

Johannessen said in a statement that McGowen’s death had caused “great concern,” but that it “hardens” his commitment to fix the Barstow operation and impose “sweeping changes” throughout the department.