Posted on December 8, 2004

How Whole Departments Fail A Hospital’s Patients

Charles Ornstein and Tracy Weber, Los Angeles Times, Dec. 7

Brenda Nelson hurried though the doors of Martin Luther King Jr./Drew Medical Center in October, toting a container of gumbo soup for her son, Mario. She expected him home soon.

To her surprise, she was told that Mario, 28, was in intensive care. There, a security guard repeatedly refused to let her in. When she finally was allowed through an hour later, nobody told her what she would find.

Mario was dead, his eyes and mouth open.

“I screamed and hollered,” she said recently, her hands trembling. “I tried to pull my baby out of the bed.”

Then she closed his eyes.

A nurse told Nelson that Mario — the family’s chief party planner and cook, and a onetime church choir director — had suffered from AIDS, something she hadn’t known. The immediate cause of death was respiratory failure brought on by pneumonia.

What Nelson was not told, until The Times reported it five days later, was that the nurse assigned to keep constant watch over Mario had not. She had silenced the alarm on his vital-signs monitor, then failed to notice his heartbeat fading, according to the nurse’s suspension letter filed in her Civil Service records.

Nor was Nelson told that the nurse had allegedly falsified her son’s medical chart. According to Los Angeles County health officials, the nurse indicated that she found Mario stable at 6 p.m. — more than an hour after he had died.

“She took it in her hands to play God,” said Nelson, who has sued the county, which owns King/Drew.

Mario’s death was no isolated incident. Three King/Drew patients, all hooked up to monitors, died last year after nurses failed to notice their declining vital signs, state and federal inspectors found.

The nursing department is often considered the heart of a hospital; its failings alone can incapacitate the entire institution. The frequency of lapses in King/Drew’s nursing department suggests a systemic problem, one that goes beyond mere individual shortcomings.

In fact, a Times investigation found that such deep failings extend well beyond nursing, to at least three other areas.

Mistakes and neglect at times have debilitated King/Drew’s pharmacy and doctor-training programs, which affect nearly every patient admitted. And the newspaper found the small but essential department of orthopedic surgery to be crippled by employee misbehavior — absenteeism, profiteering, even the commission of felonies in off hours.