Edgemoor Awaits Ruling in Death : State’s Findings Could Bring a Fine of Up to $25,000

Edgemoor Geriatric Hospital, attempting to rebound from troubles that once threatened its federal funding and resulted in thousands of dollars in penalties, will likely be fined again this week in connection with the death of 93-year-old patient.

Although Lorna Doone Bone was terminally ill from a respiratory ailment when she died Jan. 9, state authorities have determined the elderly woman’s death was caused by a nurse who inadvertently inserted a feeding tube into her windpipe.

Bone’s death, which occurred about eight hours after the feeding tube was incorrectly administered, “is still under investigation at this time,” said Ernest Trujillo, district administrator of the state Department of Health Services.

But Trujillo said state investigators are merely trying to determine now what level of citation is appropriate.

“It was probably an accident, but unfortunately it occurred,” said Trujillo, who said the investigation would be concluded by the end of the week.

If the investigators suspect that improper patient care directly caused Bone’s death--a “class double A violation”--the hospital could face fines up to $25,000, Trujillo said. The maximum fine would be only $1,000, however, if investigators determine that improper or negligent care merely increased the “possibility of harm” to Bone.

In recent years, state health officials have slapped the facility with more than $35,000 in fines for violations that included improperly administering drugs, using unwarranted restraints and being inattentive to invalids and amputees.

But county and state officials have sought to upgrade patient care at Edgemoor with infusions of money, new staff and facility improvements. Bone’s is the first death to be seriously questioned since the improvements started late last year at the 323-bed hospital, which houses elderly, handicapped and mentally ill patients with nowhere else to turn.

Administrators at the county-run hospital had contended that Bone, who “had a history of being difficult to feed,” might have dislodged the tube herself and somehow re-inserted it into the wrong pipe.

But investigation revealed that the feeding tube was inserted by a nurse into the woman’s windpipe around 1:30 p.m. Jan. 9, said Robert Grubb, supervising deputy coroner. Bone was pronounced dead around 9:25 p.m. the same day at the county-run hospital in Santee.

Grubb said it is “really not that unusual” for feeding tubes to be incorrectly inserted into a patient’s trachea instead of its intended target--the esophagus.

Normally, both patient and medical personnel recognize the error immediately.

“But someone like that, 93 years old . . . really can’t tell you that something is amiss,” Grubb said.

The state probe into Bone’s death began last month as a routine inquiry, triggered when hospital administrators made the required notification to state health officials of an “unusual occurrence,” Trujillo said.

Bone’s son, who asked not to be identified by name, said he was unaware until earlier this month that his mother’s death had been considered unusual. He said an Edgemoor doctor informed the family in a telephone conversation that the death was under investigation and that the press was inquiring about it.

“I have no direct knowledge of anything,” the man said.

“It appears that anything that happens at Edgemoor, there are going to be questions,” the man said.

David Janssen, the county’s chief assistant administrative officer, said he does not want to comment on Bone’s death “until we get the state’s report in hand.”

But Janssen said Edgemoor has made a significant turnaround since last year, regardless of the state’s conclusion.

“The fact that the state gave Edgemoor its full certification several months ago indicates there have been spectacular improvements made,” Janssen said.

Paul Simms, acting administrator at Edgemoor, said only that hospital personnel followed proper procedures in administering the tube.

Last May, the federal government threatened to withhold $8 million in Medicare and Medi-Cal funds because of problems identified in those probes.

County officials say they would have been forced to close the facility, although many of its patients have nowhere else to turn, had they not satisfied the federal government that an improvement plan was being implemented.