Unexpected Deaths at Grossmont Hospital

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Background

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.

Concerns

• Agreement relating to Quality Assurance and Patient Care Reports - Specifies that immediate reports will be made, given specific criteria, to the GHD CEO (Barry Jantz), and "...if requested, GHC's shall provide a report concerning the event to the GHD Board." By the position of these sentences, it is implied that the GHD CEO would make the sole determination as to the appropriateness of informing the GHD Board. There is no mention about any changes requiring the CEO to inform the GHD Board.

Timeline

• 21 Mar 2008 - 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, and he died.
• 11 Apr 2008 - Jeffrey Christopher, 25, of Bonsall became unsettled 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. Christopher died that night.
• 29 Jul 2008 - state Department of Public Health released a 100-page report on the matter.
• 04 Aug 2008 - special meeting of the Grossmont Healthcare District Board. The Grossmont Healthcare District's board of directors said they were unaware of the hospital's problems.
• 15 Aug 2008 - Regularly scheduled meeting of the GHD board where they introduce the new policy for communication. This meeting was filmed by Citizens Oversight.
• 18 Aug 2008 - COPs submits CPRA request to GHD.

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