Four More Lapses in Patient Care at King/Drew Reported
A seriously ill patient died at Martin Luther King Jr./Drew Medical Center after nurses failed to respond “for an extended period” to audio alarms signaling his distress -- the seventh death in two years in which staffers have virtually ignored vital sign monitors, Los Angeles County health officials said Tuesday.
The incident, which took place in March, was one of four reported to the county Board of Supervisors in the last week in which patients allegedly received questionable care. Three of the cases occurred over four days last month.
The disclosures come eight months after the county, under pressure from federal regulators, pledged millions of dollars to hire a turnaround firm to overhaul King/Drew. Although most county supervisors offered little public comment on the news, it could strengthen the board’s interest, already expressed by a majority, in handing the beleaguered public hospital near Watts over to a private company.
“Each week, we ask these questions and hear of more horror stories,” said Supervisor Mike Antonovich. “The board is in the position of hammering mercury to the wall. The sooner we can start the outsourcing process, the better it will be for patients at the facility.”
“It’s just one thing after another, with the eyes of the world on this hospital,” said Supervisor Don Knabe. “It is outrageous. How many times can you say the word publicly? You can yell, scream, jump up and down, but things don’t seem to change.”
In the March incident, a patient in the cardiac unit was attached to a monitor so that his vital signs could be tracked constantly. According to a health department memo sent to the Board of Supervisors on Tuesday, none of the four nurses on the unit responded when alarms signaled that the patient was in distress. By the time one of them noticed the patient’s condition, he could not be resuscitated.
Health officials said they did not learn of the incident until more than two months later, when a tipster alerted them.
Officials declined to provide further details of the case, but it was reminiscent of six other deaths in monitoring units since July 2003. In some of those cases, nurses were found not just to have neglected patients as they were dying, but to have turned down audio monitors or lied about their actions on patient charts. Several of the nurses have been fired. One nurse, who recently had her state nursing license revoked, wrote on a chart that a patient was not in distress, even though the woman’s heart had stopped.
In June, one troublesome incident was quickly followed by another at the hospital, which serves mostly poor and minority neighborhoods. On June 19, Father’s Day, a surgeon brought his teenage son into the operating room to observe a surgery, according to county officials and Tuesday’s health department memo to supervisors. The surgeon’s son was wearing his father’s King/Drew identification card, officials said.
“The surgeon ignored concerns expressed by nursing staff about the inappropriateness of his actions and his failure to obtain proper consent from the patient,” the memo said. “The physician refused to remove his son from the operating room.”
The orthopedic surgeon involved, Dr. Eleby Washington, said Tuesday that no one told him his 19-year-old son’s presence was inappropriate at the time.
“He is a pre-med student,” he said. “He was just observing. He didn’t participate in any patient care at all.”
The doctor said he believed there was a general consent of patients to allow students to watch medical procedures at teaching hospitals. He said he gave his son one of his white doctor’s jackets to wear, which had his identification on it.
“It wasn’t my intention to deceive anyone,” Washington said. “I introduced my son to everyone when I came in.”
The day after that incident, a dialysis patient who was supposed to be under a nurse’s observation was forced to rouse the staffer from sleep, officials told the Los Angeles Times.
The nurse fell back asleep until awakened by an alarm as blood spurted from the patient’s dislodged catheter needle, the officials said. The patient’s blood pressure plummeted, but she suffered no lasting harm, they said.
Two days later, a psychiatrist transferred a patient to another hospital without performing a medical evaluation, a potential violation of federal patient dumping rules, the health department memo said. The case has been referred to health regulators for review, officials said.
The doctor involved, Frank E. Pinder, denied improperly transferring anyone to another hospital. He said he discharged a mental patient, who had been at the hospital for at least two days after being brought in by police on an emergency hold. The patient, who did not want to leave, tried to hurt himself with a nail file, Pinder said, and he was told that the man was taken by hospital police to Harbor-UCLA Medical Center.
“Why they took him there I have no idea,” he said. “Who gave them the order to take him there, I have no idea.”
All four of the recent cases remain under investigation by the county, officials said. One of the county nurses involved in the care of the patient who died in March has been suspended without pay pending results of the probe. Two other nurses will be similarly suspended, said Mike Henry, county personnel director. The fourth nurse, hired from a temporary service, was let go, officials said.
When the incidents came up Tuesday at the weekly board meeting, Antonovich questioned county health officials and Kae Robertson, a director with Navigant Consulting Inc., the firm being paid $15 million to run King/Drew for a year.
“I just don’t understand how the people in the facility -- some of the people -- continue to misuse their public trust,” Antonovich said.
The officials had no explanations.
“All the publicity with regards to issues at that hospital, to have this occur, I can’t explain it,” said Henry, the personnel director. “But we are going to take the disciplinary actions against them.”
“It doesn’t make sense to me,” said Dr. Thomas Garthwaite, director of the county health department. “It’s outside the limits of things that I expect of physicians for sure.”
After the meeting, Supervisor Yvonne Brathwaite Burke, whose district includes King/Drew, said she was at a loss as well but was encouraged that some of the incidents were being reported to the county by the hospital’s own staff.
“I think it’s terrible that a doctor would bring his son into an operating room,” she said. “These are all terrible things. We can’t understand why they do them.”