A psychiatric patient who refused food and water for as long as 16 days died at County Harbor-UCLA Medical Center in July after the psychiatric unit staff failed to fully monitor his condition, order a medical review or begin forced feeding, according to federal records.
The man became severely dehydrated and his heart faltered. Nurses worked to resuscitate him and called a "Code Blue" for emergency help, and, despite a mix-up in defibrillator pads, were able to restore his heartbeat, records show.
A patient nearly bled to death during elective knee surgery last year at County Harbor-UCLA Medical Center when doctors had no matching blood on hand.
Harbor-UCLA officials declined to comment and did not provide an update on the patient's condition, citing pending litigation. Federal records show that soon after the surgery, the hospital prepared a new pre-surgery checklist, developed new anesthesia guidelines and made other changes.
Here is a condensed chronology based on the federal report, which identifies the patient only as "Patient B."
Aug. 5, 2011, 4 p.m. - Patient is given anesthesia before total right knee replacement surgery.
4:30 p.m. - Tourniquet applied to leg. Surgery takes longer than expected, due to complications from patient's previous leg surgery.
5 p.m. - Artery is cut in at least two places. Team postpones repairs until knee replacement is finished.
7 p.m. - New anesthesiologist takes over case during shift change.
10:30 p.m. - Tourniquet released. Patient B starts to bleed, losing 1000 cc (34 ounces) of blood. Surgeon can't stop bleeding.
11 p.m. - Blood sample sent to laboratory.
11:30 p.m. - Repair of blood vessels begins. Bleeding stops suddenly.
Aug. 6, 12:30 a.m. - Patient has no blood pressure or pulse. CPR begins. Resuscitated after receiving 14 pints of blood and four pints of fresh frozen plasma and platelets. (The average human body contains 10 to 12 pints of blood.) Vein repairs finished.
1:45 a.m. - No blood supply in right lower leg. Patient moved to intensive care unit.
Aug. 10 - Patient's right leg amputated below knee.
Aug 16 - Patient's right leg amputated above knee.
Sept. 13, 1:30 p.m. - Inspectors observe Patient B in the hospital with his eyes open, but unresponsive.
But the man died a few days later at the county-run trauma center near Torrance, according to a federal inspection report obtained by the Daily Breeze through the federal Freedom of Information Act.
His death was among a string of problems at Harbor-UCLA detailed in Medicare inspection reports since 2009. It was one of two serious lapses last summer that state inspectors documented during a Sept. 13 visit.
Harbor-UCLA officials said last week that they have made an array of changes to improve patient care, and inspectors determined in January that problems found during earlier visits have been resolved.
Harbor-UCLA is a cornerstone of emergency care in the South Bay and Long Beach area and the only Level I trauma center south of the Santa Monica Freeway.
It is also a key safety-net hospital for low-income and uninsured residents and a major teaching facility for the UCLA David Geffen School of Medicine.
The second lapse occurred just eight days after the psychiatric patient's death, when a patient nearly died because of significant blood loss during an Aug. 5 elective knee replacement surgery.
The surgical patient's blood had not been typed and cross-matched in advance, delaying a blood transfusion.
Five weeks after the surgery, state inspectors observed the patient and reported, "His eyes were open but he did not respond to commands. His arms and legs were moving but without purpose."
Harbor-UCLA officials declined to provide an update on his condition, citing pending litigation. The hospital conducted its own investigations of the two cases, but the reports are not public documents, officials there said.
The Harbor-UCLA officials said in interviews and written comments last week that they have instituted widespread changes in the psychiatric unit and elsewhere to prevent similar failings in the future.
New CEO responds
Delvecchio Finley, who became the hospital's new chief executive officer in early October, said last week that Harbor-UCLA has high standards in caring for its patients.
"In those cases where we didn't meet that standard, we work very hard to refine and retool our processes to correct them and to make our organization stronger," Finley wrote in an email on Thursday.
In one change, made after the two incidents last summer, the county's chief medical officer now meets at least monthly with Harbor-UCLA officials "to review and discuss issues including patient safety, quality improvement, and other issues," federal records show.
The Sept. 13 inspection was one of three such visits in less than two years where state inspectors found that Harbor-UCLA had failed to comply with Medicare guidelines. In response, federal officials repeatedly threatened to cut off its Medicare funding, a step that could close the hospital.
But the hospital emerged from that shadow last month.
Federal regulators wrote Finley on March 8 that they were restoring the hospital's Medicare standing. The letter followed a Jan. 12 visit by state inspectors who concluded that Harbor-UCLA was again complying with Medicare's rules.
"We're glad that they're back in compliance, and we just hope that's sustained," said Rufus Arther, manager of the non-long-term care branch of the Division of Survey and Certification at the regional office of the Centers for Medicare and Medicaid Services.
Arther declined to say if Harbor-UCLA's poor performance in three successive inspections was unusual.
"Our expectation is that a hospital will always be in compliance," he said.
Medicare generally conducts unannounced surveys of hospitals at least once every three years, frequently using inspectors from the California Department of Public Health, as was done at Harbor-UCLA.
Department officials said they are satisfied the hospital has taken steps to prevent earlier problems from recurring.
"This hospital has demonstrated receptiveness and willingness to making changes in correcting violations identified during the surveys," state officials wrote in an email.
The recent federal inspections - in October 2009 and February and September 2011 - uncovered a variety of problems, such as a backlog of radiology reports, unsanitary conditions, aging facilities, and, most recently, poor care in psychiatry and surgery.
After each inspection, the hospital produced lengthy correction plans targeting problems, with the result that they fared well in those areas in the next visit. Yet even as inspectors noted improvements, they found new failures in patient care.
The most serious lapses, chronicled in the Sept. 13 inspection report, involved the death of the psychiatric patient, referred to as Patient A, and the near-death of the surgical patient, Patient B. The report does not give the names of the patients or the doctors and nurses who treated them.
County coroner's records, however, provide details of the death of a 39-year-old Santa Monica man who matches the description of Patient A. The Breeze is not reporting the man's name for privacy reasons and because it has not contacted his family.
The man died at Harbor-UCLA on July 27, 2011, after refusing to eat while on a psychiatric hold at the hospital, coroner's records show. The chief causes of death were multiple organ failure and lack of oxygen after cardiac arrest. Other conditions listed: "probable effects of malnutrition and electrolyte disturbances."
The man was admitted to Harbor-UCLA on July 9, 2011, via the psychiatric emergency room after exhibiting bizarre behavior, federal inspection records show.
He would not talk to doctors or nurses. Nor would he eat.
"The patient refused all oral intake including medications, any physical examinations, and vital signs," records show. The staff did not call in an internal medicine doctor to check his physical condition, inspectors found.
"There was no medical or nursing assessment documented for dehydration, malnutrition, failure to thrive and/or suicidal ideation. There was no medical consultation sought to assess for dehydration despite minimal to no witnessed intake of food or water for a total of approximately 16 days," the inspection records state.
Doctor gets court order
One doctor obtained court permission to give medication to the patient, but no similar order was obtained to feed him, the records say.
The patient's heart rate had risen to 137 on July 24, compared with a normal rate of 60 to 100, but inspectors found no record that a physician was informed.
At 5 a.m. the next day, the staff discovered his heart was weakening. When it stopped, they began cardiopulmonary resuscitation and declared a "Code Blue," an all-out call for an emergency response to a cardiac arrest.
Typically, doctors and nurses rushing to restore a patient's heartbeat use a "crash cart" equipped with a defibrillator and other tools. The psychiatric unit has its own crash cart, although a Code Blue is rarely called for a psychiatric unit patient, hospital officials said.
As the nurses got Patient A's heart beating again, the staff discovered that the defibrillator pads stored on the cart were the wrong type, according to the inspection report. Nor could the staff find matching pads in the supply room, the report said. The staff located a working defibrillator, the report states, but it says that the mix-up meant that defibrillation - shocking the heart - "could not be performed immediately."
That does not match the findings of the hospital's internal report, said Kimberly McKenzie, acting chief of clinical operations at Harbor-UCLA.
The mix-up did not delay care, she said. The patient did not immediately need the defibrillation, and when he later developed an arrhythmia requiring it, the correct equipment was on hand, McKenzie said in an interview.
Patient A died in the intensive care unit a few days later.
Harbor-UCLA officials, in written responses to questions from the Breeze, said the hospital lacked the legal authority to force-feed Patient A. Psychiatric patients have the right to refuse all treatment unless a judge rules that the patient lacks the ability to give informed consent, except in a medical emergency, they said.
Harbor-UCLA's own review of the patient's death, officials wrote, has prompted changes in the treatment of a patient who "refuses to eat for more than 5 days without other means of nutrition support or refuses to drink for more than 2 days without receiving IV or enteral fluids." If that occurs, a dietitian will review the patient's nutrition and an internal medicine doctor will assess the patient's condition.
"If the patient's medical status is potentially life threatening, and the patient lacks capacity to give informed consent for treatment, appropriate medical action will be taken to prevent harm to the patient," Harbor-UCLA officials wrote.
If a psychiatrist determines that a patient lacks that capacity, a court order could be requested for treatment such as food and water, they said.
The state Department of Public Health also has found fault with Harbor-UCLA, issuing fines after four incidents in 2008 and 2009. One fine stemmed from inadequate care of an emergency patient who died, according to state records.
State officials have investigated the psychiatric patient's death and the surgical patient's injuries, but the findings have not yet been made public.
Meanwhile, the county has settled several lawsuits alleging poor care at the hospital, including two cases announced in late March.
Harbor-UCLA officials have said that the medical center, which is licensed for 538 beds but has a budget for only 373 beds, has been hampered by overcrowding and an aging campus. Construction is under way on a $322.6 million wing for surgery and emergency care, due to open in July 2013.
The hospital's leadership changed last year with Finley's arrival and the abrupt disappearance of its chief medical officer, Dr. Gail V. Anderson, who was placed on indefinite leave in September for undisclosed reasons.
Harbor-UCLA declined to comment on his current status, calling it a personnel issue. Anderson also is on leave from his post as associate dean at the UCLA medical school, said UCLA spokeswoman Dale Tate.
UCLA's responsibility at Harbor-UCLA is limited to academic issues, and the county is solely responsible for clinical care at the hospital, Tate said in an email.
Responding to questions about the Sept. 13 inspection report, she wrote, "UCLA has no involvement with the cases you have cited or with the (Medicare) inspection since those are clear issues of clinical care."
Staff Writer Larry Altman contributed to this article.
Writer Deborah Schoch can be reached at firstname.lastname@example.org
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Note to readers: This project is the result of a partnership between the Daily Breeze and the California HealthCare Foundation Center for Health Reporting. The center is an independent news organization devoted to reporting about health care issues that concern Californians. It is headquartered at USC's Annenberg School for Communication & Journalism and funded by the nonprofit, nonpartisan California HealthCare Foundation.