Details of Hospital’s Failure

Times Staff Writers

Medication errors, blood-stained equipment, expired baby formula and inattentive care were just a few of the reasons why Martin Luther King Jr./Drew Medical Center flunked a make-or-break federal inspection this summer.

In a 204-page final report released to the public late Friday, officials at the U.S. Centers for Medicare and Medicaid Services explained how the Willowbrook hospital, near Watts, fell short in nine of 23 healthcare categories, prompting the government’s decision to quit providing $200 million in annual federal funding.

When the failure was revealed last month, the Los Angeles County Board of Supervisors swiftly moved to merge the hospital with another county-run medical center, while preserving King/Drew’s emergency room -- a vital facility in a region plagued by violence.


So the document released Friday served mostly to underscore the extent of the hospital’s problems, which started with management and extended to the pharmacy, nursing, infection control and other operations.

King/Drew Chief Executive Antionette Smith Epps and other officials continue to dispute many of the findings. At several points in the report, which included the county’s response, hospital officials detail procedural changes or extra employee training that have taken place since the inspections.

County health department chief Dr. Bruce Chernof declined to comment on the final report.

The document cites shortcomings throughout the hospital but focuses mainly on three areas -- the way medicine was administered, errors by staff and the hospital’s general lack of upkeep. All three have been identified as problematic in previous federal reports on King/Drew.

Inspectors found that hospital workers did not properly dispense some medications.

“At the time of the survey it was not clear what the facility’s guidelines for the use of propofol were,” inspectors wrote of a common anesthetic. “During the survey, three different policies/protocols for the use of propofol were provided to the survey team.”

The report added: “These policies/protocols were not in agreement and provided conflicting information.”

In another case, there were four different formulas for a common cocktail of drugs to treat gastrointestinal problems. And inspectors found that an employee who had been fired still had access to an automated drug-dispensing machine at the hospital.

“The facility was not aware that an ex-employee still had possible access to medications,” inspectors wrote.

One person, identified as “Patient 17” by inspectors, was the subject of several medication errors, the report said. First, hospital workers failed to quickly give Mucomyst -- used to break up thick mucus. In addition, two intravenous antibiotics were administered to the patient after they were ordered discontinued by a physician. And two anticonvulsant medications were not administered as ordered.

Hospital equipment was improperly maintained in some cases, the report said.

“Visible blood was observed on the outside surface of point-of-care testing devices, which could result in an exposure to blood-borne pathogens” such as hepatitis B, inspectors wrote.

Other key findings:

* On Aug. 1 inspectors found 66 bottles of baby formula in the neonatal intensive care unit that had an expiration date of July 1. Hospital officials blamed housekeeping staff for not notifying the neonatal staff.

* There were no appropriately trained staffers in Unit 3E to watch cardiac monitors. Hospital chief Epps replied that there were “no assigned observers because the monitoring was being done by direct observation of the patients by personnel with significantly higher levels of competence ... than that of a monitor observer.”

* Employees were not properly washing their hands before handling food.

* Temporary nurses were not adequately trained to provide pain medication.

* Patient records often lacked important information.

* Inspectors witnessed one staffer attending to a patient’s foot abscess without washing his hands enough after changing his gloves, and placing soiled gloves on top of clean bandages.

* A fluid pump in the intensive care unit was “observed to be coated with a thick dried yellowish substance.”

Federal officials informed the county in June that because of problems found at King/Drew in the preceding years, the hospital would be the subject of one final, thorough inspection over the summer.

On July 31, about a dozen inspectors arrived at the hospital unannounced, said Steven Chickering, the associate regional administrator for the Medicare agency, on Friday.

“We ask our teams to make observations in terms of care being delivered or provided, medications being administered, those kind of things,” he said. “There are also times we may ask if there are certain procedures that we want them to walk through.” In addition, he said, inspectors interviewed staff and patients and reviewed medical records.

The report was delivered to the county last month, but the county did not release it until Friday, after it had finished responding to federal officials’ allegations.

Through a spokesman, Supervisor Yvonne Brathwaite Burke, whose district includes the hospital, declined several requests to comment.

But Supervisor Zev Yaroslavsky said the findings had persuaded the entire board that it was necessary to merge King/Drew with Harbor-UCLA Medical Center near Torrance.

“It wasn’t a close call,” he said. “In a sense” the report “liberated us to do what we should have done a couple of years ago.”

Supervisor Mike Antonovich said he was pleased that federal inspectors didn’t water down their findings because of the community’s sensitivity over the hospital. Inspectors did not “ignore the medical tragedies that were occurring regularly at that facility,” he said.