CMS Report Highlights Treatment Errors at King/Drew
CMS inspectors on Wednesday made public a report that found nine patients at Martin Luther King Jr./Drew Medical Center were not given "vital antibiotics" and breathing treatments, the Los Angeles Times reports. The report identified problems in three of the 21 areas that federal inspectors reviewed, including patients' rights, nursing and the facility itself.
The "most serious" problems in the report involve medication errors, the Times reports. Inspectors found that four emergency department patients did not receive vital antibiotics that their doctors ordered. Some of those patients never received the medications, while others got them hours late. In addition, five patients did not receive Albuterol, a medication used to treat breathing disorders, as ordered by doctors. County health officials said that when the report was conducted, King/Drew was in the middle of changing how breathing medicines are distributed and no problems have occurred since.
The report also identified problems in nursing care, in which psychiatric nurses had to manage services for as many as 22 mental patients each -- far more than the number allowed by law -- and that the skills of temporary nurses were not thoroughly reviewed before they began work. In the report, an inspector said that a nurse changed a patient's chart after the inspector pointed out to the nurse that she did not, as required, record that a patient felt abdominal pain or if the pain decreased after she injected him with morphine. That nurse no longer is employed by King/Drew, hospital officials said. King/Drew officials also said that the hospital has changed staffing levels in the psychiatric ward.
Inspectors also cited King/Drew for physical plant problems, including holes in walls and ceilings, improperly stored food and soiled mattresses in the psychiatric emergency services ward. Inspectors said, "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." County officials said that they have replaced mattresses.
According to the Times, the new findings "echo some of [the problems] in inspections released within the last eight months," in which inspectors identified "chart fabrications, neglect and errors in the cases of five patients who died at the medical center." The most recent report does not link any of the nursing problems or medication errors with patient deaths. However, CMS said King/Drew risks a loss of federal funding, which accounts for more than 50% of its $350 million budget.
Los Angeles County Department of Health Services Director Thomas Garthwaite and other officials on Wednesday said that the latest cited problems were different than the ones identified previously by CMS. Garthwaite said, "It would be very unlikely to look this hard and not find something." Hospital leaders said that identified problems have been corrected by the crisis team, appointed by last fall by the county department of health and headed by the department's Chief Operating Officer Fred Leaf. The team has been overseeing day-to-day operations at the hospital.
Steve Chickering, spokesperson for CMS, said that his agency has not decided whether to accept the team's plan of corrections or to require more changes (Ornstein/Hymon, Los Angeles Times, 8/5).