King/Drew Treatment Errors Cited

Just two months after being reprimanded for rampant medication errors, Martin Luther King Jr./Drew Medical Center failed to give vital antibiotics and breathing treatments as directed to nine patients, a federal inspection has found.

King/Drew, owned and operated by Los Angeles County, also has lingering problems in its nursing care, according to the report made public Wednesday. Health inspectors found that psychiatric nurses had to oversee care for as many as 22 mental patients each -- far more than allowed by law -- and that the skills of temporary nurses were not adequately checked before they began work.

The same report, from the U.S. Centers for Medicare and Medicaid Services, cited a nurse who improperly changed entries on a patient’s chart -- in front of an inspector -- when questions were raised about her conduct.

The findings echoed some of those in inspections released within the last eight months, in which reviewers found chart fabrications, neglect and errors in the cases of five patients who died at the medical center, which is in Willowbrook, just south of Watts.

The most recent report does not link nursing lapses or medication errors to any patient deaths.

But this time, inspectors went on to cite King/Drew for failings in its physical plant -- for holes in walls and ceilings, crusty and soiled mattresses, and a day-old roast beef that was much too warm despite being in a refrigerator. Two refrigerators and a freezer had no thermometers.

The hospital failed even to get basic facts right, such as patients’ weight and height, inspectors found. One patient hospitalized after a car accident was said to weigh 275 pounds on April 2, 400 pounds on April 4 and 194 pounds on April 28. No one noticed the discrepancy until it was pointed out by an inspector more than one month later -- and a nurse could not explain it. She speculated that the patient could have been weighed on a bed scale when miscellaneous equipment was left on it.

In another case, records showed that a patient went from being 5-foot-1 and 135 pounds to 4-foot-7 and 110 pounds in the space of three days.

The report is the fourth since January citing systemic problems with patient care at King/ Drew. Among other things, inspectors have found that county police inappropriately used Taser stun guns on psychiatric patients, and nurses failed to track the vital signs of patients attached to heart monitors.

The most recent inspection, conducted in May and June of this year, was a follow-up to earlier reviews.

The findings come as a crisis team, appointed last fall by the Los Angeles County Department of Health Services, is overseeing the hospital’s day-to-day operations. That team, dispatched after major problems surfaced at the hospital, is led by the health department’s second in command, Fred Leaf.

The federal government is threatening to cut off its share of funding to the hospital, which accounts for more than half of King/Drew’s $350-million budget. Hospital leaders said Wednesday that all of the problems identified in the report have been corrected and that they are seeking to keep federal funding.

Hospital and county leaders said the latest report should not be interpreted as bad news for King/Drew. Federal inspectors reviewed 21 areas within the hospital and found serious problems in only three: nursing, patients rights and physical environment.

“It would be very unlikely to look this hard and not find something,” county health director Dr. Thomas Garthwaite said. “I guess I’m not shocked that they can still find a few things, but I think there’s good evidence that there’s been progress.”

Garthwaite and other officials also said Wednesday that the latest problems were different from those identified previously. The medication errors happened in the emergency room this time, not the inpatient wards. And the nursing issues largely dealt with temporary staff, not permanent employees.

Steven Chickering, a regional manager with the federal health agency, said his staff had not decided whether to accept the hospital’s plan of correction or to require more changes.

The most serious findings in the latest report involved medication errors.

Inspectors found that four emergency room patients didn’t receive vital antibiotics ordered by their doctors -- and no one seemed to notice. Some never got their drugs; others got them hours late.

Five other patients did not receive Albuterol, a drug used to treat breathing disorders, as ordered by doctors. From May 18 to 20, one patient did not receive six of the doses ordered and received the wrong dose seven other times, inspectors found.

County health officials said that at the time of the survey they were in the midst of changing how they distributed medications to ease breathing, and no errors have happened since the change.

The hospital has been trying to fix the way it administers medications since February, when it wrongly gave a potent cancer medication for four days to a patient with meningitis. Federal inspectors in March found that the same patient had been the victim of more than 40 subsequent errors.

In this month’s report, inspectors also questioned the care given to a patient treated for abdominal pain in May.

A nurse did not, as required, document why the patient was having pain or if it receded after she gave the patient a morphine injection.

After an inspector pointed out the deficiencies in the patient’s chart, the nurse inappropriately added the information after the fact, inspectors said.

King/Drew fired the nurse, who was a temporary employee, hospital officials said.

Inspectors outlined a host of problems with the physical conditions at the hospital.

In the psychiatric emergency services ward, for instance, inspectors learned in May that patients often slept on old mattresses on the floor in a day room because of a lack of beds.

“All the mattresses were soiled and had what looked like dried, crusty secretions on the cover,” inspectors noted.

The mattresses were actually old gurney pads. When inspectors returned the following month, the pads had been replaced with mattresses that inspectors also found to be in various stages of disrepair. One mattress had a broken handle on the side, which inspectors said patients could remove to cause harm to themselves.

“The hospital failed to ensure that each patient received care in an environment [comfort, dignity, infection control] that a reasonable person would consider to be safe,” inspectors said.

County officials say they have replaced the mattresses and improved staffing in the unit so nurses tend to fewer patients.

“I think the hospital and the staff are doing a diligent, diligent job in moving forward and correcting these problems,” said Leaf, the head of the crisis team.

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Weight problem

Federal inspectors found that employees at Martin Luther King Jr./Drew Medical Center recorded the following weights for a patient who was admitted April 1 after a car accident. A nurse told inspectors that she could not explain the discrepancies.

April 2: 275 pounds

April 4: 400 pounds

April 7: 310 pounds

April 27: 262 pounds

April 28: 194 pounds

May 15: 301 pounds

May 18: 356 pounds

May 19: 272 pounds

Source: U.S. Centers for Medicare and Medicaid Services