State health officials slapped an immediate ban on admissions to a West Baltimore nursing home yesterday, citing a pattern of medication errors along with a curious incident in which nurses wrote on a medical chart that they cared for a patient who in fact wasn't there.
After issuing the ban on Poplar Manor Nursing Home, Deputy Health Secretary Nelson J. Sabatini said he questioned whether the home's medical director, Dr. Mark Davis -- who also has an ownership stake in the home and cares for all 157 patients there -- could possibly deliver a decent quality of care while assuming so many roles.
"It eliminates what I think are some important checks and balances," Mr. Sabatini said.
Ordinarily, he said, a medical director oversees the work of other physicians who treat patients in the nursing home -- looking over their shoulders, in effect, to make sure they are treating people properly.
But nothing in the state medical laws and regulations precludes the practice of serving as both medical director and rank-and-file doctor, while also reaping profits that flow into the home. Mr. Sabatini said developments at Poplar Manor may prompt the health department to propose new rules to limit responsibilities.
Dr. Davis called the allegations of shoddy care "unfounded and without merit," adding that he would probably appeal the ban.
"If their research was better and they had done more homework, they would not have come to those conclusions," he said.
Health department inspectors spent 10 days surveying conditions and reviewing records before officials issued the ban.
The health department cited several instances in which Dr. Davis and nurses gave potentially toxic levels of medication to sick patients. In another instance, officials faulted nurses for calling a private ambulance service for a tube-fed person who had trouble breathing rather than getting a faster response by dialing 911.
"The patient was finally transferred to the hospital . . . nearly two hours after her signs and symptoms were first noted," said the inspection report. "The patient expired during the night."
Officials faulted Dr. Davis and nurses for failing to treat the patient's labored breathing as an emergency, although they did not blame the patient's death on delayed medical attention.
Mr. Sabatini said he was particularly troubled by errors made in patient charts. In two instances:
* Nurses noted in the records that they turned a 65-year-old man in his bed every two hours from June 1 to June 8. During this time, he was actually in the hospital, undergoing treatment for an adverse reaction to medication.
* A physician wrote that a woman's pupils appeared "sluggish" but that both reacted to light -- even though her left eye had been surgically removed and replaced with glass.
"Charting errors appear pervasive, and they reflect on the plan of care and the condition of every individual in that place," said Mr. Sabatini. "Clearly when you're charting progress on someone who is not in the facility at the time, this may be something akin to fabrication."
Dr. Davis said staff may have accidentally erred on the charts or put a true statement on the wrong chart. But he denied that anyone deliberately falsified the charts.
Mr. Sabatini's critical remarks came about a year after he asked the state Board of Physician Quality Assurance to investigate Dr. Davis' medical practices, following findings of widespread lapses in medical care at the Dukeland Nursing Center, where Dr. Davis also supervised care.
The board, which has the power to suspend or revoke medical licenses, has not issued any sanctions against Dr. Davis. But Mr. Sabatini said he intended to ask the board to look into the doctor's actions further, adding: "It would certainly not trouble me were the board to consider the appropriateness of an emergency suspension."
The health department gave the nursing home one month to correct its problems. Mr. Sabatini said the department has the power to halt the home's Medicare and Medicaid reimbursements and to strip its operating license if it fails to meet the timetable.
Poplar Manor received $2.1 million in Medicaid reimbursements in 1989 and has received $1.7 million so far this year. Medicare figures were not available.