Scripps Mercy Hospital could lose all government payments after a federal investigation into the death of one patient revealed extensive pharmacy delays, nursing shortages and management failures at its Chula Vista and Hillcrest campuses.
K.C. ALFRED / Union-Tribune
Pharmacist Michael Falcon and nurse Jojie Baluyot discussed a patient's medicine yesterday in the intensive care unit at Scripps Mercy Hospital in Chula Vista.
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Regulators said the facilities failed because of three “immediate jeopardy” situations – those in which policies or practices caused or were likely to cause death or serious harm.
Federal officials threaten to withhold money only when they find that such incidents indicate systematic failures in patient care. Hospitals in this type of crisis must quickly overhaul their procedures.
In San Diego County, Sharp Grossmont Hospital in La Mesa also is struggling to show regulators that it has fixed its array of deficiencies, including those that contributed to at least three deaths since March.
The Scripps Mercy problems were first identified at the Chula Vista facility, after the hospital reported to health regulators the Feb. 29 death of a critically ill woman who never received a saline solution ordered more than four hours earlier.
Health investigators inspected both campuses and found many other lapses, including nurse-to-patient ratios that fell below state requirements, lack of pharmacy review for drugs administered in the emergency departments and recovery units, and health workers who failed to guard against adverse drug interactions.
They detailed these shortcomings in a 188-page report that Scripps gave to The San Diego Union-Tribune last week.
A major bottleneck stemmed from the lack of available inpatient beds at the Chula Vista campus. Patients in the emergency room who needed to be admitted often were placed on “hold” for up to 24 hours, but without physician oversight.
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Patient care problems
Health investigators found three “immediate jeopardy” situations – ones that caused or could have caused death or serious harm – among the two Scripps Mercy hospitals in Chula Vista and Hillcrest:
 Staff members in the Chula Vista hospital's emergency department labeled all prescriptions sent to the pharmacy as needing immediate attention. This lack of prioritizing delayed delivery of saline to a patient who died before it was administered.
Both hospitals failed to meet California's mandatory nurse-to-patient ratios for critical care, and some nurses lacked training on how to care for patients with neurological problems or heart attacks.
Staff members at both hospitals did not safeguard against adverse drug interactions, and the pharmacies did not double-check prescriptions for the emergency departments and recovery units.
Sources: Scripps Mercy; Centers for Medicare and Medicaid Services
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“The 'hold' patients were monitored and had care provided by nursing staff only,” the report said. Investigators also said doctors' requests for medications, tests and other procedures “were not reliably followed.”
In addition, emergency department staff members at both hospitals failed to help pharmacists prioritize medication orders because they labeled every prescription as “STAT,” or “immediately.”
The investigators found that some nurses lacked training on how to monitor patients with neurological disorders and didn't know how to properly manage heart-attack patients.
Also, staff members didn't obtain patients' consent for certain procedures. At the Hillcrest facility, patient privacy was compromised because medical records could be viewed in patients' rooms.
Overall, Scripps Mercy's two campuses were found lacking in five crucial categories of patient care: its governing body, quality assurance, medical staff, nursing services and pharmacy services.
Continued failure in even one area could disqualify Scripps Mercy from receiving Medicare and Medi-Cal funds, which account for more than one-third of its revenue.
“It's a big concern when there are immediate jeopardy situations. Our first priority is to protect patients,” said Deborah Romero, deputy chief of survey and certification at the Centers for Medicare and Medicaid Services' regional office in San Francisco.
Among the 450 hospitals in that office's jurisdiction of Hawaii, California, Nevada and Arizona, 10 to 12 a year have five or more major lapses. Nearly all of them eventually resolve their crises and keep their government payments.
Scripps Mercy has corrected or is working to fix all the problems, said its CEO, Tom Gammiere, and the chief of its medical staff, Dr. Jerrold Glassman. The hospital's executives sent a detailed correction plan to Medicare officials Aug. 8 and are awaiting a response.
“We need to do a better job of identifying who's in charge of the patient at any given point in time when they're in the hospital,” Glassman said.
However, Glassman said, faster action would not have saved the woman's life Feb. 29. The patient was so sick, he said, that “delivery of medication at any time would not have changed the outcome.”
Gammiere said hospital reporting laws that took effect last year in California have provoked unprecedented “zealousness” among health regulators. “It's a new day for hospitals under this kind of oversight and scrutiny,” he added.
The quality issues came to light after Scripps Mercy reported the Feb. 29 death, as required by state law, on March 4.
The woman originally came to the Chula Vista emergency room on Feb. 28 with low blood-sodium levels and then left against medical advice, the report said. She returned at noon the next day in much worse condition, with high blood pressure and severe breathing problems.
Lab tests completed by 2:20 p.m. showed that her blood-sodium levels had dropped even lower, but intravenous sodium was not ordered until 6:35 p.m. The pharmacy did not get the solution to the patient's bedside for hours.
“(The nurse) received the . . . saline at 10:45 p.m. but was told to take a break, so she left the bag on the bedside table and planned to administer it when she returned. But during her absence, the patient coded and expired,” the report said.
State health investigators said patients were put in “immediate jeopardy” because of the slow pharmacy turnaround times for STAT orders. They also found other systemwide issues and asked the federal government to authorize a wider investigation.
The federal team, with many of the same state investigators, returned April 1 for a week to scrutinize both Scripps Mercy campuses. Its members identified two more “immediate jeopardy” situations.
They reviewed medical records for dozens of patients, interviewed physicians and nurses, and scrutinized hospital policies and procedures.
Pharmacy operations were a key issue.
For example, an order for calcium gluconate, required for a 7-day-old infant, was filled only after nurses ordered it a second time. Even then, it took 90 minutes for the order to arrive – much longer than the 15 minutes called for, the report said.
Investigators also reported hearing medical staff members complain about “differences in culture” between the emergency department staffs at the Hillcrest and Chula Vista campuses.
Yet “there was no evidence of collection of data illustrating how these differences affected patient care,” the investigators wrote.
Scripps Health acquired Bay General and renamed it Scripps Chula Vista in 1986. Eight years later, after the Chula Vista hospital lost more than $50 million over three years, Scripps united the Hillcrest and Chula Vista facilities under one Scripps Mercy license.
The consolidation has brought about greater efficiency. But some changes have been slow to come, Glassman said.
“We're doing everything together now: holding joint meetings, having joint celebrations, all the things each (campus) did before on its own,” he said. “That's what's going to merge the cultures over time.”
Cheryl Clark: (619) 542-4573; cheryl.clark@uniontrib.com
