HomeMy WebLinkAboutMINUTES - 03311987 - 2.2 r4,'
THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Adopted this Order on March 31, 1987 by the following vote:
AYES; Supervisors Fanden, Schroder, Torlakson, McPeak
NOES; None
ABSENT; Supervisor Powers
ABSTAIN; None
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SUBJECT; Statement of Deficiencies and Plan of
Correction - Merrithew Memorial Hospital
The Board received the attached report dated March 20,
1987 from Mark Finucane, Health Services Director, regarding the
transfer of patients from Brookside Hospital to Merrithew Memorial
Hospital.
IT IS BY THE BOARD ORDERED that the report from Mr.
Finucane is ACCEPTED.
IT IS FURTHER ORDERED that the Health Services Director
is DIRECTED to send letters to the County' s Legislative Delegation
with respect to the lack of funding for public health care systems.
cc: Health Services Director
County Administrator
I hereby certify that this Is a true andcorrect copyot
an action taken and entered on the minutes of the
Board of Supervisors on the date shown.
ATTESTED: /A4A-C-k a,,, If'? 1
PHIL I3ATCH-ELOR, Cleric of the Board
of Supervisors and County Administrator
By r` �.i , Deputy
..a
2-002
j CONTRA COSTA COUNTY
-77 HEALTH SERVICES DEPARTME
Sr'c'ur``';.
MAR ;� 01887
CONTRA COSTA
HEALTH SERVICES ADMINI15TRATION
To: Board of Supervisors Date: March 20, 1987
Phil Batchelor, County jAdmilFrom:
strator
i
Mark Fi nucanef2L'" / Subj t: Statement of Deficiencies
Health Services Director and Plan of Correction
The attached "Statement of Deficiencies and Plan of Correction" from the State
Department of Health Services resulted from the transfer of two patients from
Brookside Hospital to Merrithew Memorial Hospital on the night of March 4 and
the early morning of March 5, 1987.
In my opinion, with the exception of the failure to .report, the deficiencies are
relatively minor and do not indicate any systems problems. The death of the
infant was. being investigated internally by the Hospital Quality Assurance
Committee. As a result of that action, Dr. Steve Tremain, Dr. William Walker,
and Frank Puglisi were aware of the incident and I was advised immediately upon
my return from vacation on March 16.
An attempt was being made to gather more information from Brookside before
reporting the incident to the State. However, the deficiency, as contained in
the State's report is a valid one, and we will respond immediately with a Plan of
Correction.
You have all heard and read much about the testimony of Dr. Robert Pond before
the Assembly's Health Subcommittee. Consequently, I have included a copy of a
memo from Dr. Pond to Dr. Scott Herold, Emergency Room Medical Director. This
details the circumstances of three transfers from Brookside which resulted in the
State's finding, of deficiencies, and apparently motivated Dr. Pond' s testimony.
I received a copy of this memo on March 17, the day that Dr. Pond testified in
Sacramento.
Mr. Puglisi and Dr. Tremain are collaborating in the following areas:
1. The required Plan of Correction to the State's Finding of Deficiencies.
2. All of the circumstances described by Dr. Pond in the attached memo
and in his testimony.
Upon completion of their work and after my review, I will report to all of you
their findings. Of course, both County Counsel and our outside counsel will be
consulted to determine the proper forum.
MF:LB:bgg
encls.
AB-LB-CITES
A-41 3/81
STATE OF CALIFORNIA—HEALTH ANb WELFARE AGENCY GEORGE DEUKMEJIAN, Governor
DEPARTMENT OF HEALTH SERVICES
2151 BERKELEY WAY "
BERKELEY, CA 94704 '
March 20, 1987
D
Mark Finucane, Administrator
Department of .Health Services
Contra Costa County
2500 Alhambra Avenue
Martinez, CA 94553
Dear Mr. Finucane:
The enclosed HCFA 2567 addresses the deficiencies we discussed on
3/18/87. Please respond with an appropriate plan of correction
that addresses who will be responsible for and by what date
corrections will be made.
We are requesting that the EMS System incorporate a receipt
mechanism to be left with the sending hospital for all intra-
hospital transfers.
Sincerely,
4sv h-Z4/Wf-;4 . /n 6
Leon Starkman, M.D.
Medical Consultant
Licensing & Certification
Enclosure
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{ t .memo
j To: Scott Herold, M.D. Medical Director of the emergency room of
of Merrithew Memorial (Contra Costa County) Hospital
From: Bob Pond, M.D. Family Practice Residents
Subject: Recent unstable inter-hospital transfers
I want to bring to your attention the facts relating to three transfers to
Merrithew Memorial Hospital occuring on 3/3/87 to 3/5/87. All three of these
transfers originated from the same hospital and were arranged by the same. M.D.
Case Number 1(J. H.; 4t ): Involved the transfer of a 31 year
old woman who was placed on 5150 restraint as a danger to herself
because her husband suspected she had taken an excess of heroin or
cocaine. I received the transfer call from Dr. M. about 5 or 6 a.m.
3/3/87. The woman was said to have a "good blood pressure". Dr. M.
.)aid that she had been somewhat lethargic on arrival so she was given
some narcan and with this she "perked up". No mention was made of
any head trauma. I accepted the transfer.
The woman arrived in the Merrithew E.R. 30 to 60 minutes later.
We transfered her from the ambulance gurney to a chair and noted
that the woman became unresponsive and slumped forward. her blood
pressure sitting up was unobtainable. She was moved to one of our
gurneys and although she then became arousable she remained
lethargic. She was given a total of 4 amps of narcan without much ft ---
any
any improvement in her mental status. Her blood pressure remained'_
in the range of 90 systolic. At this point I reviewed the records
transfered with her from the other hospital. Her blood pressure there
was noted to have been 80 systolic while her diastolic blood pressure
was unobtainable. She had been given 2 liters of fluid before
transfer. The emergency room record noted that her mental status
showed "little improvement with narcan",
in our emergency room the woman's glucose came back as 60.
She was given glucose and vigourous IV hydration and her shock and
lethargy began to slowly resolve. She was noted, to have bruises
around her eyes. She spoke of being beaten in the head by the fists of
a friend. She was ultimately admitted to the hospital for observation
and further hydration.
Case Number 2(D.H.;-;1�088193): Involved a 25 year old roan who had
admitted to using PCP and unspecified other drugs. The man was
markedly agitated and violent and it had taken 5 policemen to subdue
him. The mm was on 5150 restraint and taken to the nearest.
before
'a
3/4/87 a phone call was made from this E.R. to the mental health
screening department of our hospital and the patient was accepted for
transfer directly to the county hospital acute psychiatric ward
without evaluation in our emergency room. I was not involved in
accepting this transfer so I am not sure of what information was
conveyed over the telephone about the patients history or physical
exam or treatment at the transfering hospital. It was Dr. P1. who made
this call.
On arrival at the acute psychiatric ward the patient was found to
be near comatose (he made a few spontaneous movements but did not
open his eyes or verbalize or move in response to deep pain).
Conversations with the paramedics revealed that the police had
repeatedly and forcefully beaten the patient in the back of the head
and chest while attempting to subdue him. Exam of the patients scalp
revealed a superficial laceration and underlying hematoma. Review of
the records transfered with the patient from the other hospital
showed that the patient had been given 15 mg of Haldol including 10
mg just before transfer (the recommended dosage for this
circumstance is 2 to 5 mg with subsequent dosing given after waiting
1 hour).
The patient was transfered from our acute psychiatric ward to
our E.R. His mental status was unresponsive to narcan and his
laboratory work up (aside from a tox screen which is pending) was
normal. After several hours in the E.R. and after an emergency C.A.T.
scan (negative) the patient was admitted to the medicine service
with a diagnosis of concussion with multiple drug intoxication.
Case Number 3(A.G.;-"1456893) Involved a 33 year old pregnant lady
in labor. She had once seen a doctor in San Francisco several months
previously. Otherwise she was without pre-natal care. She thought
that she was due "either February or March". Her last menstrual
period was "sometime in June" (making her 36 to 40 weeks by dates).
On 3/4/87 at about midnight Dr. M. spoke with me on the telephone
regarding transfer of this patient. He refered to this patient. as
"term", Given the available information this was clearly a rash
conclusion. After he had finished his presentation (the woman's
cervix was "long and fingertip") I asked him what the fundal height
had measured to. "40 centimeters", he said. I accepted the transfer.
"How wild you send this patient? By ambulance?" I asked. "I don't
want to use an ambulance, but unfortunately they have no other means
of transport", he replied.
The Wornan arrive(j io our E.R. 90 minutes later. I measured her
i..iridal fe11hC to '� �;rnDio the doctor at the othFr hospital �,o this
easurern�nr :;::r� i,er ''Jo. He c4ldn't do Mal ,
she answered. Vaginal exam showed she had dilated to 5 cm and was
1002o effaced. I reviewed the records transfered with the patient. Up
to 2 hours and 15 minutes had elapsed between the time that the
woman was examined vaginally and the time that Dr. I'l, had spoken
with me on the telephone. The information he had given me was not
current. Altogether the woman spent 2 hours and 50 minutes in the
other E.R. During this period the fetal heartrate was measured only
once or twice and at no time was any electronic fetal monitoring
performed. Given the fact that this woman was at high risk of
complications (she had had essentially no pre-natal care and the
fundal height strongly suggested that her baby was either pre-mature
or growth retarded) the standard practice would have been either to
monitor the heartbeat continuously with electronic fetal monitoring
or (if the electronic machines were unavailable) to check the
heartrate intermittantly every 15 to 30 minutes and for at)east 30
seconds after a uterine contraction,
i admitted the.woman to our labor and delivery ward. A brief
period of monitoring showed severe and prolonged decelerations in
the fetal heart rate. Shortly thereafter the fetus was delivered with
no heartrate and no respirations. 40 minutes of CPR was
unsuccessful and the baby was pronounced dead. The fetus weighed.4
lbs 13oz, making a fundal height of 40 cm extremely unlikely at anv
time during the pregnancy.
These three case have several things in common. They were late night
transfers of medically unstable patients. They were all arranged by the same
physician working in the same E.R. in each case there was a significant
discrepancy between the information presented over the telephone and the facts
recorded on the transfering emergency room record or the facts ultimately
revealed. i am sure that at the time of transfer the transfering doctor was not
aware of all the factors which ultimately made the patients unstable. To the
extent that this is true I suggest that he should take greater care in considering
the available data and ordering further tests. But I also suspect that in certain
respects there was a conscious effort to mislead on the part of the transfering
physician.
I end this memo with a question:
What should be done to prevent such
things from happening again ?
Steve rumen. rpSl��ent. !-ledical 5 iff of llerr t.riew Memorial Hf�coitai
1,1a,rk' !nj._ar, . norCounry Der)artme-nt of Health
(lr�r �'Ir:R{�:�, ',� ",lr _ :�!u ':.t_5!a LlunTv boar,, o1♦r jr,)erv1
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