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State cites preventable deaths in report on Sharp Grossmont

Union Tribune (2008-07-30) Cheryl Clark

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More Info: Local Politics, Grossmont Healthcare Board

Hospital could lose all federal payments

By Cheryl Clark


July 30, 2008

Sharp Grossmont Hospital in La Mesa could lose all federal payments for patient care because of serious problems – some of which resulted in preventable deaths – according to a report released yesterday.


Sharp Grossmont Hospital in La Mesa has the county's busiest emergency department.
The mistakes, documented by state investigators during two inspections in April and May, included staff members restraining a highly medicated, 25-year-old man with schizophrenia in such a way that he was allowed to suffocate. In addition, hospital workers caused the death of an 83-year-old woman who had undergone a hysterectomy by injecting a dangerous anti-narcotic into her bloodstream.

Other problems included nurses who did not know or use proper CPR, an unsanitary operating-room mattress held together by tape and glue, unsafe storage and handling of food and kitchen equipment, and use of critical medications such as heparin that had expired up to a year earlier.

The investigators also said Sharp Grossmont did not have the required specialists to evaluate emergency patients needing urologists or hand, plastic and oral surgeons. Sharp Grossmont has the busiest emergency department in the county, with about 78,000 patient visits a year.

Loss of federal reimbursement would cripple most hospitals, including Sharp Grossmont, which receives 50 percent of its net patient revenue from Medicare and Medicaid, known as Medi-Cal in California. The two programs cover treatment for seniors, the poor and the disabled.

Dan Gross, executive vice president of Sharp Health Care, said he was confident the hospital is now in compliance.

“I'm a nurse, and my heart is with every patient and every family,” Gross said. “We at Sharp are so unhappy and so keen to determine what we missed, what could we have done differently and what can we do better. We have an expectation that we provide nothing but the highest quality of care.”

In the spirit of acknowledging Sharp Grossmont's faults and efforts to correct them, Gross provided a copy of the 100-page federal report one day earlier than the government's planned release.

Sharp Grossmont's leaders had until yesterday to document how they had fixed or are addressing the deficiencies. On the deadline day, they hand-delivered their “Plan of Correction” to the Center for Medicare and Medicaid Services' regional office in San Francisco.

Regulators will review the hospital's response and schedule another visit by state inspectors, who work on behalf of the federal government. Sharp Grossmont could lose its federal money by Oct. 15 if problems continue, said Steven Chickering, head certification officer at Medicare's office in San Francisco.

Among the 450 hospitals in Chickering's jurisdiction of Hawaii, California, Nevada and Arizona, 10 to 12 a year have as many major lapses, he said. Ninety-nine percent of those facilities resolve their crises and keep their federal payments, Chickering said.

The violations at Sharp Grossmont “indicate a serious breakdown of the hospital's systems that are designed to ensure appropriate patient care,” said Kathleen Billingsley of the state Department of Public Health, which inspected Grossmont's quality of care.

Chickering called the problems “significant” in five of 18 critical categories: oversight by the hospital's governing body, observance of patient rights, monitoring and improving quality of care, nursing services and physical environment.

“These areas really need close attention and significant changes to ensure good outcomes for the patients,” Chickering said.

Gross and Michele Tarbet, Sharp Grossmont's CEO, said they have launched intense educational programs and taken disciplinary action against employees to put the hospital back on track.

They also said hospital officials have dramatically beefed up professional training of nurses and other staff members, launched rigorous reviews of the psychiatric unit and re-evaluated food storage and maintenance of food-preparation equipment.

Sharp operates the hospital under a long-term lease with the public Grossmont Healthcare District, which opened the hospital more than a half-century ago.

Gloria Chadwick, who serves on the district's board, said she and other board members knew nothing about the problems.

“Certainly it would be a public discussion, but there's been nothing like that at all,” Chadwick said. “This is certainly a concern for the community.”

The deficiencies at Sharp Grossmont first came to light in April, a few weeks after Larry Napolis, a 45-year-old heart attack victim, was placed on a ventilator in the hospital's catheterization lab. The ventilator was not turned on, said state investigators and the San Diego County medical examiner.

Napolis died March 21. The fatality was not reported promptly to state and federal officials as required, state investigators said.

As a team of state inspectors looked into the case in April, another preventable death occurred at Sharp Grossmont.

Jeffrey Christopher, 25, of Bonsall was playing cards with his mother on April 11 and became agitated when visiting hours ended at the hospital's psychiatric unit. Christopher had a history of becoming unsettled and then falling to his knees, resulting in wounds to his knees and feet.

The unit's workers took Christopher to his room and had him lie down on his stomach. They secured him to his bed with restraints at the wrists, ankles and waist, keeping his head and neck above the mattress. They also gave him several medications for his schizophrenia, including ativan and thorazine.

Although nurses continuously monitored Christopher, they did from a chair facing his feet instead of following the standard practice of checking a patient's face. One nurse assigned to his room said she saw him “scoot and wiggle himself lower onto the bed until his face was on the mattress,” according to a report by the county's medical examiner, who conducted an autopsy on Christopher.

“He then began violently hitting his face against the mattress and metal frame of the bed,” and held his breath, the medical examiner's report said.

During a staffing rotation, another nurse entered the room and saw that Christopher had turned blue.

The Medicare report said a nurse tried to resuscitate Christopher, but did not follow American Heart Association guidelines because he had not been trained adequately. Christopher died that night.

At least one-quarter of the federal report, which did not mention Christopher by name, is devoted to chronicling the series of errors that resulted in his death.

“The staff did not intervene by repositioning the patient onto his back so that he would be unable to bury his face in the mattress,” it said.

The federal report also faulted Grossmont officials for not reporting this death until six days after it happened. The government requires official notice within a day.

Gross and Tarbet, the Sharp executives, said a licensed vocational nurse who was watching Christopher didn't notice that he had suffocated.

“The (nurse) assumed that since the patient had been sedated, he was resting quietly,” Tarbet said.

Attorney Peter Haven is investigating Christopher's death for his parents, Barbara and James Christopher of Bonsall.

After learning about the federal report's contents, Haven said the inspections “confirm what we already suspect – that restraints were used inappropriately in at least one instance, and it appears there may be more widespread problems at this medical center.”
Cheryl Clark: (619) 542-4573;

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Title State cites preventable deaths in report on Sharp Grossmont
Publisher Union Tribune
Author Cheryl Clark
Pub Date 2008-07-30
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Keywords Local Politics, Grossmont Healthcare Board
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Topic revision: r3 - 16 Sep 2009, RaymondLutz
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