nurses failed to adequately examine the patients

[pickledpepperRN]

November 8, 2003 - Times Headlines

Hospital Blamed in 2 Deaths

By Tracy Weber and Charles Ornstein, Times Staff Writers

A state report finds that one King/Drew patient's heart stopped and another ceased breathing without anyone noticing.

Nurses and other employees at Martin Luther King Jr./Drew Medical Center botched the care of two women who died there this summer, failing in one case to notice that a patient's heart had slowed and stopped over 45 minutes, according to a state report released Friday.

Inspectors from the California Department of Health Services found that nurses failed to adequately examine the patients and that some apparently had never been taught to use new bedside monitors at the hospital. In addition, one nurse lied about performing crucial tests ordered by a doctor, the report said.

In both women's cases, a technician assigned to watch a central monitor displaying patients' vital signs was also given other duties. It is unclear if anyone was watching the monitor when the technician was away or when the women needed emergency attention, state health inspectors said.

Los Angeles County, which owns King/Drew, has reassigned the technician while it conducts its own investigation and has changed the rules so monitor technicians may do nothing but watch the monitors. County officials also reported a nurse to the state nursing board for documenting care that was not provided to one of the women, said Laura Sarff, director of quality improvement for the county Department of Health Services.

After being questioned by officials, the nurse has failed to show up for work again, Sarff said.

Cynthia Millage, whose mother, Robbie Bilbrew, was one of the patients whose care was criticized in the state report, said Friday that the findings didn't surprise her, because she had her own concerns about the treatment at the time.

"But it just hurts me to think about it," Millage said. "It hurts me a lot to even talk about it."

Since the women's deaths, July 4 and July 15, the county's investigation has focused largely on potential problems with a new monitoring system that was installed in late June. In September, hospital officials disconnected the $411,000 system, in part because nurses said that they were worried it wasn't reliable and that it hadn't alerted them to the two women's distress.

The state report did not address whether the system itself failed, but raised questions about the staff's training and mistakes made in using the monitors.

In one case, an incorrect identification code was entered into the computer, meaning the patient's vital signs did not show up on the central monitoring system. As a result, the central alarm didn't sound when her condition changed, staff members told the state inspectors.

The woman, Sonia Lopez, 33, had stopped breathing when a physician discovered her at 6:27 a.m. June 30. Although she was resuscitated, she died July 4.

Ana Lopez, Sonia's sister, said that even if her sister's monitor was hooked up incorrectly, someone should have noticed that she had stopped breathing.

"Why didn't they check?" Lopez asked.

In the case of Bilbrew, 52, state inspectors zeroed in on the lack of documented care and contradictions in the records.

On the afternoon before her death, a doctor ordered respiratory therapy to keep the level of oxygen in her blood high. But the nurse assigned to Bilbrew did not document her oxygen levels, nor did it appear the therapy had been provided, inspectors found.

Bilbrew's cardiac monitor records show that her heart rate began to slow at 5 a.m. July 15. By 5:08, her heart rate indicated that she was near death, and at 5:27, her heart stopped. According to her chart, however, cardiopulmonary resuscitation was not started until 5:45. Bilbrew was pronounced dead at 6:35 a.m.

The state report indicated that a doctor had ordered numerous tests on Bilbrew, including blood work and a chest X-ray, to be done at 2 a.m. "Staff interviews revealed the [nurse] never ordered the tests, although the [nurse] had signed the orders as completed," the state report said.

The state found other discrepancies: A nurse wrote on Bilbrew's chart that she was checked at 5:30 and "was in no acute distress." By that time, actually, her heart had stopped.

The nurse also indicated that at 6 a.m., the patient was given routine oral and IV medications. The state inspectors said, however, that at the time, the patient "had no IV in place."

The hospital had planned to release Bilbrew to a skilled nursing facility that day, and had written on her chart that she was "ready" to be discharged, according to the state.

After the deaths, county officials said they had introduced additional training for the staff on using the monitors and the need to both perform and document procedures ordered for patients.

"There was a breakdown in the management of patient care in that unit," said John Wallace, county health department spokesman.

The state report does not carry any immediate penalties for the hospital, but county officials must quickly draft and implement a plan to correct the violations. Inspectors have the option of requesting a full-blown survey of the hospital's problems by the U.S. Centers for Medicare and Medicaid Services, which could lead to sanctions against the hospital, including loss of federal funds.

It is the latest in a series of problems for King/Drew, in Willowbrook just south of Watts. The hospital must shut down its radiology and surgery doctor-training programs in June because of serious deficiencies. And county officials have put a new management team in place to help the hospital restore fiscal order.

In addition, the county continues to investigate why the new monitoring system was purchased in the first place.

The system is set up so a central station receives information from bedside monitors tracking the blood pressure, heart rate, blood oxygen level and temperature of up to 60 patients.

The monitors' manufacturer, Welch Allyn Inc., has stood behind the equipment. But its own investigation in August found physical damage to the central monitoring unit at King/Drew that could have caused its speakers to malfunction in one of the cases, company officials said.

Relatives of both women said Friday that they had never been told by King/Drew staff that anything but unavoidable medical problems led to the deaths. But even before the state report, they said, they had their suspicions about the quality of care. Their requests for basic services such as clean sheets and baths were ignored by nurses, they said.

"I knew they weren't taking care of my mom. I knew it," Cynthia Millage said.

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[canoehead, BSN, RN]

That is shameful.

[Buddha]

As a Nurse I am embarressed by what happened, but wonder what the ratio per Pt/Nurse was and wonder what was the unit manager in charge was doing. Checks and Balances is definently needed here. My sympathy goes out to the familys of both women.

[kwagner_51]

PLEASE don't get me wrong on what I am about to say but, since when do hospitals have "basic services"? I thought that belonged in Hotel/motel management!! See Quote below from article;

"Their requests for basic services such as clean sheets and baths were ignored by nurses, they said."

If what I am reading is true, nurses don't have time to PEE, let alone give a bath/change sheets.

I want to know where the supportive help was. Also, to the nurse that didn't do proceedures and said she did, SHAME ON YOU!!

Nusres work their a****s off trying to help their patients. They don't have time to change sheets and give baths!!!

Sorry, getting off my soapbox now.

[weezieRN]

Being a new RN 5months, I know how hard it is to manage between 8-15 pts. Sometimes during the night shift you go in and assess them at the beginning of your shift and If they don't call out and are continent all you usually do is a walk by to see how they are doing. My other comment is if these women were in such a fragile state why were they on a regular m/s floor? Why didn't they have more frequent vitals taken/ordered seems to me there was alot of things missing in all aspects of their care. What were their admitting dx etc. I know I miss things occassionally when you are overwhelmed but it seems as if something major was not passed along through the doctor or prior nurse's report and the fact that the tele was not working is not good in itself. Our tele system is ancient and it alarms for the least little thing leads off etc. We do not have a tech monitor the tele just staff.

[weezieRN]

Wow I missed part of the article about what all their monitoring system does. To me something that sophisticated should have a back up. This sort of system leads to less patient contact and the simple "how are you feeling" which can mean a lot. Another thing is if the tech was not at the post who was monitoring all these patients for one hour? I don't know why administration seems to think you can do more with less. (staffing)

[Hellllllo Nurse, BSN, RN]

Originally posted by Buddha

As a Nurse I am embarressed by what happened, but wonder what the ratio per Pt/Nurse was and wonder what was the unit manager in charge was doing. Checks and Balances is definently needed here. My sympathy goes out to the familys of both women.

Same here.

[live4today, RN]

Documentation of "assessing the patient" and not just relying on "the monitor" may have alleviated this awful situation with those families loved ones.

When I use to work nightshift, I carried a flashlight and would check every patient q 2 hours by using my flashlight to make sure they had "unlabored/easy respirations"...in other words...still BREATHING.

Even now that I work dayshift, if a patient is napping, I still make sure they are alive and kicking whether they like the interruption or not because keeping my license and career intact depends on my "assessing the patient" and not just the monitor.

[IamRN]

Originally posted by weezieRN

Being a new RN 5months, I know how hard it is to manage between 8-15 pts. Sometimes during the night shift you go in and assess them at the beginning of your shift and If they don't call out and are continent all you usually do is a walk by to see how they are doing.

But how often do you check on them? Depending on your state nurse's practice act and/or hospital policy you may be legally required to check/assess them on a regular basis...more regular than at the beginning of the shift and at the end of the shift.

[Rapheal]

Yes this is shameful but I wonder about the signed off orders for 2 am. Could the doc have ordered labs and an x-ray without putting it as stat. If so the nurse may have believed it would be done in the a.m., such as during the routine morning labs and then the x-ray. And if this is what happened, then by seeing these orders entered in the computer- she would sign them off believing she had done what was required at that time.

Why weren't these patients in ICU? All in all it is a tragedy.

[mattsmom81]

and I had a lot of questions reading this article.

I have worked with monitor techs who adjusted all alarms so monitors would rarely alarm. I've had monitor techs announce 'they're taking a break' and run off when they finally SEE the dangerous rhythm...to let the nurses handle it. Looking back in the system I have found dysrhythmia was occuring for a loooong time but the tech did not notice it until too late. This is one reason I no longer work charge on our telemetry unit, I don't want the liability...I do not trust the skills of the facility's 'monitor tech' and the facility will not pay a nurse to watch the monitor.

There may be more culprits here than just the alarm settings but this is one possiblity that occurred to me as I read the article.

I hope the system is looked at and not just the nurses. :stone

[bellehill, RN]

I agree this is very embarressing to the profession of nursing. No wonder our pts don't trust us with articles like this!