Another Death at Hospital Is Probed

With a make-or-break inspection around the corner, Martin Luther King Jr./Drew Medical Center officials are looking into another unexpected death -- this one involving a woman who fell and later died after wandering away from a unit where she was supposed to be connected to a cardiac monitor.

King/Drew officials reported the June 9 death to state regulators Tuesday after a “comprehensive internal investigation,” according to a statement issued Thursday by the Los Angeles County Department of Health Services.

“This death was unexpected, and the investigation is continuing, but the facility’s review indicates that the patient received appropriate care,” the statement said. Citing the family’s wishes and privacy laws, the department declined to disclose additional information.

The state health department said it will investigate the case as it does all reported events and complaints.

Two people familiar with the matter said the woman had been told not to leave her room after she was admitted last week to the public hospital near Watts. Nonetheless, she left her fourth-floor monitoring ward to smoke a cigarette outside the hospital, said the sources, who spoke on condition of anonymity because the county has told employees not to discuss the incident publicly.

After she fell and was discovered, the hospital called a code blue emergency, one of the sources said. When staff members responded, they assessed her and took her back upstairs to her unit, not to the emergency room, according to the source.

The Times could not immediately determine how or where the woman fell or whether she was knocked unconscious.

An emergency room resident physician who responded to the code did not accompany the patient upstairs, nor was the patient connected to a portable monitor after the accident, as is standard at many hospitals in such circumstances, the source said. A short time later, the woman went into cardiac arrest and died, the sources said. The cause was not disclosed.

The death comes as King/Drew is preparing for an inspection by federal regulators within the next 2 1/2 months that will determine whether the hospital keeps $200 million in U.S. funding, about half its budget.

If King/Drew fails any part of the unannounced top-to-bottom inspection, it stands to lose the money, and county supervisors say they will have little choice but to downsize the hospital, close it or give it to someone else to run.

To prepare, King/Drew invited staffers from other county hospitals to conduct a practice review last week. They found unspecified problems, some of which were described to the county Board of Supervisors in a closed session Tuesday.

King/Drew has been repeatedly cited for lapses in care that have led to patient deaths -- at least three of them in the same unit where the latest patient walked away.

Hospital-wide, at least seven patients have died since 2003 after staffers virtually ignored vital sign monitors. 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.

At a recent staff meeting at the hospital, King/Drew Chief Executive Antionette Smith Epps and other senior administrators implored employees to be vigilant and remember the basics. They said that nurses needed to diligently record their observations in patient charts and that pharmacists must follow through on all medication orders, an attendee said.

“These aren’t new areas,” Epps said in an interview earlier this week. “These are areas for continued diligence.”

Epps, who took over as administrator in October, said that although her job has been tough, she believes the hospital is ready for the federal inspectors to arrive. She would not, however, speculate on the outcome.

“I’m not a Las Vegas oddsmaker,” she said. “I’m a hospital administrator. All I can tell you is I am continuing to prepare my staff every day. We are using every resource that the county of Los Angeles will bring to bear to make sure that we are indeed able to demonstrate that [King/Drew] is a safe place for patients.”

Epps said she is trying to change the culture at the hospital and restore accountability. “Unfortunately, with our workforce and in the community,” she said, “there are people who sort of lament for the good old days.”

But she said that “the gold old days are never quite as good as some people remember,” adding that 20 years ago, patients could be more easily restrained in their beds to prevent them from getting up.

“I don’t think anybody really wants to go back to that,” she said. “They want to go back to a time when they were very confident in the care that was provided” at King/Drew.