Latest King/Drew Lapse Blamed in Patient’s Death

A 28-year-old patient died at Martin Luther King Jr./Drew Medical Center on Thursday after a nurse turned down the audio alarm on his vital-signs monitor in the intensive-care unit, then failed to notice the man’s heart was barely beating, Los Angeles County health officials confirmed Monday.

A physician trainee walking by noticed the monitor screen flashing, indicating that the patient was in distress, but was unable to revive him, officials said.

While investigating the death, hospital officials discovered that the man’s nurse had falsified his medical chart, noting that he was stable at a time when he was already dead, officials said. The nurse, who was caring for one other patient, apparently made the note earlier in the day but indicated her observations were made at 6 p.m. The patient died about 4:30 p.m.

The death comes as the county-owned hospital, serving a largely poor and minority population near Watts, is struggling for its survival. In recent months, King/Drew has lurched from one crisis to another, facing repeated threats to its federal funding and national accreditation because of failings in patient care.

In fact, Thursday’s death is strikingly similar to three cases at King/Drew last year in which government health inspectors determined that patients had died after nurses did not watch their cardiac monitors as patients’ vital signs deteriorated.

In one of those cases, a nurse wrote in a chart that the patient was not in distress, even though a subsequent review of monitor printouts showed the woman’s heart already had stopped beating at the time. It was unclear when the entries were falsified.

“It’s just unbelievable that it could happen again,” said county Supervisor Don Knabe of Thursday’s death. “I would think that every nurse, every doctor would be on their best behavior.”

It is unbelievable, as well, to Ana Lopez, whose 33-year-old sister died in July 2003, after being neglected in the cardiac monitoring unit.

“It just breaks my heart to see nothing’s been done,” Lopez said. “I don’t think it’s a nurse’s decision when a patient goes. It’s God’s decision.”

The patient who died Thursday had AIDS-related pneumonia, county officials said. But a King/Drew physician who reviewed the man’s chart said he did not appear to be at risk of imminent death, they said.

“You don’t need to have a high school diploma to know this is a disaster,” said Supervisor Zev Yaroslavsky. “This is dishonest. It’s corrupt. It’s morally bankrupt, and it’s dangerous -- and in the case of this patient, exceedingly dangerous.”

County officials did not identify the patient or the nurse involved, citing confidentiality restrictions. The nurse, described as a veteran of many years, has been suspended, they said.

John Wallace, a spokesman for the county Department of Health Services, said it was unclear why the nurse had lowered the monitor’s alarm volume to an inaudible level. Nurses can adjust the volume of monitor alarms depending on whether they are in the room or down the hall.

Federal officials said the incident would trigger yet another investigation at King/Drew.

Just a month ago, county supervisors reluctantly proposed closing the hospital’s trauma unit, the county’s second busiest, so King/Drew could focus on fixing myriad problems in other units.

The nursing department, however, already was supposed to have undergone substantial reform. Ten months ago, after the third patient died while connected to a monitor, the county hired an outside turnaround firm, Camden Group, to revamp its operations and ensure that nurses were competent.

“I recognize it takes time, but they’ve had enough time,” said Supervisor Yvonne Brathwaite Burke, whose district includes the hospital. “We have to get nurses under control. There has to be better supervision. There’s no question about that.”

Dr. Thomas Garthwaite, director of the county health department, said Monday that he wasn’t sure any firm could ferret out dishonesty.

“It’s hard to fathom” that after last year’s deaths, “someone would be stupid enough to turn down the alarm,” he said.

He also confirmed that his department had started disciplinary actions against two other King/Drew nurses who were discovered late last week to have falsified patient records.

One fabrication was found as a result of a medical malpractice suit, and the other during routine reviews of patient charts. Both nurses are working but not caring for patients while the county investigates, Wallace said.

An official with the nurses union called the incident “very, very tragic” but said it didn’t reflect the overall conduct of King/Drew’s nurses.

“The vast majority of nurses at King/Drew are very ethical and care greatly about their work and their patients,” said Nick Builder of Service Employees International Union Local 660.

It was unclear how Thursday’s incident would affect the stance of regulators and accreditors toward King/Drew. Some already have proposed their harshest possible sanctions against the hospital.

A national hospital accrediting group has recommended pulling its seal of approval, which could lead to the closure of doctor training programs and the loss of nearly $15 million in private insurance reimbursements.

Separately, to stave off a loss of $200 million a year in crucial federal funding, the county entered into a strict agreement last month with the federal government. As part of the agreement, the county pledged to hire an outside company to run the entire hospital.

Jeff Flick, regional administrator of the U.S. Centers for Medicare and Medicaid Services, said his agency might have to reconsider its funding of King/Drew after Thursday’s death.

“Stuff like this is just plain disturbing,” Flick said.