Long Beach Memorial escapes Medicare funding loss after serious patient care lapses – Press Telegram


During an anxious week in April, Long Beach Memorial Medical Center teetered on the point of losing its Medicare funding after state inspectors uncovered a pair of dangerous incidents that put patients in immediate jeopardy of significant injury or possible death.

The primary 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 lady died lower than a month after she was admitted to Long Beach Memorial.

“This systemic failure led to a medicine error that might potentially cause harm or serious adversarial 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 doesn’t say whether the standard of care the lady 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 tool used to stop blood clots. The patient sustained a fractured hip and was found on the ground by a nurse. An alarm designed to stop such falls by alerting staff when a patient leaves a bed had not been turned on.

Doctors decided to not repair the patient’s hip, believing the surgery was unlikely to enhance 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.

Inside days, the immediate jeopardy designations were removed and the specter of losing Medicare accreditation was lifted after inspectors validated the hospital’s corrective motion plan through staff interviews and record reviews.

“Patient safety is our top priority, and we’re deeply committed to providing the best 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 make sure the security of patients, Steele said.

“We’ve got stringent processes in place to observe quality, performance and patient safety,” she said. “We are going to proceed to observe and assess the corrective actions to make sure that the hospital meets or exceeds all regulatory requirements related to the supply of patient care.”

Although Long Beach Memorial is not any longer in jeopardy of losing its Medicare accreditation, it isn’t necessarily within 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 doesn’t normally affect other consequences for harm which will have resulted from the issue … lawsuits or penalties from other regulatory agencies,” she said.

Long Beach Memorial received a “C” from Leapfrog in its most up-to-date Hospital Safety Grades rating.

Immediate jeopardy involving imminent threats of significant injury or death is probably the most serious deficiency a medical facility can face and carries probably the most severe sanctions, in line with the Centers for Medicare & Medicaid Services. Apart from the lack of Medicare accreditation, fines in California can range from as much as $75,000 for the primary violation, as much as $100,000 for the second, and as much as $125,000 for each third and subsequent violation.

The CDPH report doesn’t indicate whether Long Beach Memorial faces any civil penalties and doesn’t list the names of the 2 patients involved within the incidents involving immediate jeopardy.

 Woman administered improper drug

Nevertheless, Rosemary Davis of Long Beach identified her 88-year-old mother, Margaret Davis, because the patient who was prescribed anastrozole.

State inspectors issued immediate jeopardy citations to Long Beach Memorial Medical Center after a physician mistakingly gave cancer drugs to 88-year-old Margaret Davis (Courtesy of Rosemary Davis)

“It’s very frightening that this sort of stuff goes on and that this sort of harm is completed,” 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 various awards Memorial flaunts on their website, there are various terrifying realities which can be hidden from the general public.”

In a 15-page criticism 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 identical 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 worker on the hospital’s pharmacy.

“I went over all my mother’s current medications with him,” she said within the March 22 CDPH criticism. “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 in a phone conversation on the morning of Feb. 5, her mother sounded “weak and drained.” During one other call later that day, she was unintelligible.

“After I called back that evening to talk to her, I could barely understand her,” Davis said within the criticism. “I got on the phone with the nurse and told her I believed that there was something improper with my mother. I told her my mother gave the impression of she had a stroke. The nurse dismissed my concern and said it was just that my mother was 88 and elderly people get disorientated within the hospital.”

Amid growing concerns, Davis phoned the nurse the following day and asked for the list of medicines that had been prescribed for her mother.

“She told me several medications I recognized after which said anastrozole,” Davis said. “I told her my mother didn’t take that drug.”

Anastrozole is a hormonal treatment often used with surgery or radiation to treat early breast cancer in women. The drug could cause quite a lot of serious uncomfortable side effects, including chest pain, swelling, blurred vision and shortness of breath together with difficulty swallowing or respiratory.

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 faraway from her list of prescribed medications.

Doctor admits lack of due diligence

A health care provider identified as “Physician 1” told state inspectors he didn’t order the anastrozole and assumed the list of medicines prescribed at Long Beach Memorial was similar to those at the opposite hospital where he had previously treated the patient, in line with the CDPH report.

The doctor did, nevertheless, acknowledge not doing “due diligence” in reviewing the medication list and said he relied on safety checks by nurses and pharmacy staff.

The physician didn’t reply to phone calls and emails in search of comment.

Moreover, the CDPH didn’t reply to questions on the immediate jeopardy citations issued to Long Beach Memorial. Nevertheless, records show the agency has forwarded Davis’ criticism 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. Nevertheless, Davis believes the damage to her mother was already done.

She recalled visiting her mother’s hospital room and finding her unable to make use of a plastic spoon to scoop soft ice cream from a small cup placed on a dinner tray.

“I used to be horrified,” Davis wrote to the CDPH. “My self-sufficient mother was so impaired she couldn’t lift a plastic spoon to her mouth. And it seemed nobody at Memorial was aware of this.”

The day after Margaret Davis’ anastrozole prescription was canceled, doctors postponed her heart procedure pending the outcomes of a brain scan to find out if she had suffered a stroke, which turned out to not be the case, her daughter said. Eventually, she received considered one of the 2 scheduled surgeries.

Still, problems together with her care endured.

Davis said her mother was subjected to physical therapy despite her heart condition and a physician’s previous order to stay 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 become septic shock after which multiorgan failure before her death, said her daughter.

“My mother went into Memorial candidate for her two heart procedures,” Davis wrote to the CDPH within the criticism after her mother died. “If she had been allowed to get those procedures once they were scheduled, without being subjected to a continuous pattern of negligence, injury and harm, I could be visiting my mother at rehab as an alternative of planning to scatter her ashes.”


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