Poor care preceded 15 deaths

March 02, 1994|By Frank D. Roylance | Frank D. Roylance,Sun Staff Writer

Maryland health officials say they have found "serious" lapses in the quality of care given to 15 patients who died last year at the John L. Deaton Specialty Hospital and Home Inc., a chronic-care hospital and nursing home on South Charles Street in Baltimore.

The poor care may not have caused the patients' deaths, state authorities said yesterday. Most were elderly and already seriously ill. But, authorities said, the lapses did allow their illnesses to worsen and increased their suffering during the last days of life.

"We don't want to say one thing led to the other," said Michael Golden, a spokesman for the Department of Health and Mental Hygiene. But the problems were "serious enough that some action needs to be taken to correct them, and to assure that the quality of care [at Deaton] is at the level it should be."

Among the problems found during the state's investigation:

* A 76-year-old woman was given a tranquilizer despite records showing she was allergic to the drug. The woman, who depended on a ventilator to assist her breathing, suffered worsening respiratory distress later that day and died.

* A 74-year-old stroke patient received no diagnosis or treatment for 17 straight days of rectal bleeding. After his blood pressure began falling, he was rushed to an acute-care hospital, where he died. Doctors there found a rectal tumor.

* The bed sores noted on a 72-year-old quadriplegic man were allowed to worsen for almost two months. A week before he died, one sore grew so deep that his heel bone became visible.

* An 88-year-old patient was found dead, with cool skin. The patient was supposed to be checked each hour, but the last documented check was eight hours earlier.

A 136-page state report details sloppy, incomplete record-keeping, deficiencies in Deaton's quality assurance programs and the performance of its governing board, and in the supervision of its staff.

The problems could threaten the 360-bed hospital's eligibility for reimbursement by federal Medicaid and Medicare programs.

Mr. Golden said the report was being sent to the Health Care Finance Administration office in Philadelphia. If HCFA finds that Deaton no longer meets standards, the state would conduct further reviews and monitoring. Deaton would submit a plan to bring itself into compliance. If that fails, the hospital could lose its Medicaid and Medicare eligibility.

Deaton's medical director, Dr. Brian C. Wallace, yesterday defended his hospital's performance.

"Generally speaking, I don't feel . . . that the problems listed are out of the ordinary for a facility of our type," he said. Deaton's patients suffer from serious and chronic health problems and are at high risk for complications.

"It's important to realize, too, that the charts reviewed were ones already picked up by our quality-assurance program," he said.

But Mr. Golden said that of the 30 or 40 Maryland hospitals inspected annually, only three or four have problems this serious. "We do not find these problems regularly," he said. "It's pretty obvious to me that [Deaton's quality assurance programs] weren't picking up the problems. Obviously they weren't correcting them."

State authorities became aware of problems at Deaton in January after a nurse went to city police alleging that criminal actions by hospital staff members had caused the deaths of 10 patients dependent on mechanical ventilators.

Neither police nor state health officials found any evidence of criminal wrongdoing. But after investigating all 15 deaths at Deaton during 1993, the state found problems that the hospital's quality-assurance procedures failed to correct.

The nursing staff failed to recognize and respond to patients' deteriorating conditions, and failed to alert physicians to warning signs such as rectal bleeding and unstable blood sugar and blood pressure. The medical staff also failed to evaluate the effectiveness of antibiotics prescribed to fight infections.

Dr. Wallace, the hospital's medical director, said, "There are some things quoted in the report that are embarrassing.

"Perhaps we do need to look at some charts in more detail, but in general the monitoring systems here work," he said.

He said the hospital is working to improve the attendance of its physicians at meetings where patient-care issues are reviewed.

Deaton received its first national accreditation only past year, but scored poorly in an evaluation of nursing qualifications, competence and levels of staffing.

Peggy Greene, Deaton's vice president for nursing, said more registered nurses have been hired during the last six months and the hospital plans to strengthen nurses' skills in responding to "changing signs and symptoms of patients."

"I'm concerned that we still have obvious problems but . . . we're working very hard to make it better," she said. "I do not feel the report was unfair."

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