During an anxious week in April, Long Beach Memorial Medical Center teetered on the brink of losing its Medicare funding after state inspectors uncovered a pair of dangerous incidents that put patients in immediate jeopardy of serious injury or possible death.
The first incident occurred in February, when an 88-year-old woman hospitalized for chest pain was mistakingly given two doses of anastrozole, a chemotherapy drug used to treat breast cancer, a condition her family says she didn’t have. The woman died less than a month after she was admitted to Long Beach Memorial.
“This systemic failure led to a medication error that could potentially cause harm or serious adverse drug reactions to the hospital’s patients,” wrote California Department of Public Health inspectors, who spent eight days at Long Beach Memorial, in a confidential report obtained by the Southern California News Group.
The 33-page report does not say whether the quality of care the woman received at Long Beach Memorial contributed to her death.
The hospital’s second immediate jeopardy situation occurred March 12, when a patient with dementia and a history of falls attempted to walk unassisted in his room and tripped over a device used to prevent blood clots. The patient sustained a fractured hip and was found on the floor by a nurse. An alarm designed to prevent such falls by alerting staff when a patient leaves a bed had not been turned on.
Doctors decided not to repair the patient’s hip, believing the surgery was unlikely to improve his quality of life. He was placed on comfort care and died March 19.
Hospital avoids Medicare loss
State inspectors personally delivered their findings to Long Beach Memorial Chief Executive Officer John Bishop, Chief Medical Officer Dr. Joe Kim and other top executives in meetings on April 12 and 19.
Within days, the immediate jeopardy designations were removed and the threat of losing Medicare accreditation was lifted after inspectors validated the hospital’s corrective action plan through staff interviews and record reviews.
“Patient safety is our top priority, and we are deeply committed to providing the highest quality and safest care to our patients,” said Richele Steele, a spokeswoman for Long Beach Memorial. “The hospital did receive the findings from CDPH, which the hospital took very seriously.”
Corrective actions were immediately taken to ensure the safety of patients, Steele said.
“We have stringent processes in place to monitor quality, performance and patient safety,” she said. “We will continue to monitor and assess the corrective actions to ensure that the hospital meets or exceeds all regulatory requirements related to the provision of patient care.”
Although Long Beach Memorial is no longer in jeopardy of losing its Medicare accreditation, it isn’t necessarily in the clear, said Leah Binder, president and chief executive officer of the Leapfrog Group, a Washington, D.C., organization that grades hospitals based on patient safety.
“It does not normally affect other consequences for harm that may have resulted from the problem … lawsuits or penalties from other regulatory agencies,” she said.
Long Beach Memorial received a “C” from Leapfrog in its most recent Hospital Safety Grades ranking.
Immediate jeopardy involving imminent threats of serious injury or death is the most serious deficiency a medical facility can face and carries the most severe sanctions, according to the Centers for Medicare & Medicaid Services. Aside from the loss of Medicare accreditation, fines in California can range from up to $75,000 for the first violation, up to $100,000 for the second, and up to $125,000 for every third and subsequent violation.
The CDPH report does not indicate whether Long Beach Memorial faces any civil penalties and does not list the names of the two patients involved in the incidents involving immediate jeopardy.
Woman administered wrong drug
However, Rosemary Davis of Long Beach identified her 88-year-old mother, Margaret Davis, as the patient who was prescribed anastrozole.
“It’s very frightening that this kind of stuff goes on and that this kind of harm is done,” she told the Southern California News Group. “The findings of the federal Investigation into Memorial clearly illustrate that behind the smiling photos of doctors and administration posing with million-dollar donors and the many awards Memorial flaunts on their website, there are many terrifying realities that are hidden from the public.”
In a 15-page complaint to the California Department of Public Health, Davis, 60, said her mother initially was taken by ambulance to St. Mary Medical Center in Long Beach on Jan. 28 for chest pains and was treated there by a physician. The same doctor treated her after she was transferred five days later to Long Beach Memorial to undergo two heart procedures, she added.
Soon after her mother was admitted to Long Beach Memorial, Davis said she received a phone call from an employee at the hospital’s pharmacy.
“I went over all my mother’s current medications with him,” she said in the March 22 CDPH complaint. “I had also gone over all my mother’s current medications when she had been admitted to St Mary’s. I managed my mother’s medication for years.”
Davis recalled that during a phone conversation on the morning of Feb. 5, her mother sounded “weak and tired.” During another call later that day, she was unintelligible.
“When I called back that evening to speak to her, I could barely understand her,” Davis said in the complaint. “I got on the phone with the nurse and told her I believed that there was something wrong with my mother. I told her my mother sounded like she had a stroke. The nurse dismissed my concern and said it was just that my mother was 88 and elderly people get disorientated in the hospital.”
Amid growing concerns, Davis phoned the nurse the next day and asked for the list of medications that had been prescribed for her mother.
“She told me several medications I recognized and then said anastrozole,” Davis said. “I told her my mother did not take that drug.”
Anastrozole is a hormonal treatment often used with surgery or radiation to treat early breast cancer in women. The drug can cause a variety of serious side effects, including chest pain, swelling, blurred vision and shortness of breath along with difficulty swallowing or breathing.
Davis said her mother had last taken anastrozole to treat breast cancer in 2019 and was assured by Long Beach Memorial’s pharmacy staff that it had been removed from her list of prescribed medications.
Doctor admits lack of due diligence
A doctor identified as “Physician 1” told state inspectors he did not order the anastrozole and assumed the list of medications prescribed at Long Beach Memorial was the same as those at the other hospital where he had previously treated the patient, according to the CDPH report.
The doctor did, however, acknowledge not doing “due diligence” in reviewing the medication list and said he relied on safety checks by nurses and pharmacy staff.
The physician did not respond to phone calls and emails seeking comment.
Additionally, the CDPH did not respond to questions about the immediate jeopardy citations issued to Long Beach Memorial. However, records show the agency has forwarded Davis’ complaint against the hospital and doctor to the Medical Board of California.
Patient deteriorates
On Feb. 6, Margaret Davis’ anastrozole prescription was abruptly discontinued after it was deemed incorrect. However, Davis believes the damage to her mother was already done.
She recalled visiting her mother’s hospital room and finding her unable to use a plastic spoon to scoop soft ice cream from a small cup placed on a dinner tray.
“I was horrified,” Davis wrote to the CDPH. “My self-sufficient mother was so impaired she could not lift a plastic spoon to her mouth. And it seemed no one at Memorial was aware of this.”
The day after Margaret Davis’ anastrozole prescription was canceled, doctors postponed her heart procedure pending the results of a brain scan to determine if she had suffered a stroke, which turned out not to be the case, her daughter said. Eventually, she received one of the two scheduled surgeries.
Still, problems with her care persisted.
Davis said her mother was subjected to physical therapy despite her heart condition and a doctor’s previous order to remain on bed rest. “My mother should never have been subjected to that,” Davis said. “The physical therapy was dangerous and abusive.”
Margaret Davis suffered an infection that eventually turned into septic shock and then multiorgan failure before her death, said her daughter.
“My mother went into Memorial a good candidate for her two heart procedures,” Davis wrote to the CDPH in the complaint after her mother died. “If she had been allowed to get those procedures when they were scheduled, without being subjected to a continuous pattern of negligence, injury and harm, I would be visiting my mother at rehab instead of planning to scatter her ashes.”