There is a whole series at www.latimes.com which you have to register but is free to read online. azskeptic
By Charles Ornstein and Tracy Weber Times Staff Writers
Brenda Nelson hurried through the doors of Martin Luther King
Jr./Drew Medical Center in October, toting a container of gumbo for
her son, Mario. She expected him home soon.
To her surprise, she was told that Mario, 28, was in intensive care.
There, a security guard repeatedly refused to let her in. When she
finally was allowed through an hour later, nobody told her what she
Mario was dead, his eyes and mouth open.
"I screamed and hollered," she said recently, her hands
trembling. "I tried to pull my baby out of the bed."
Then she closed his eyes.
A nurse told Nelson that Mario the family's chief party planner
and cook, and a onetime church choir director had suffered from
AIDS (news - web sites), something she hadn't known. The immediate
cause of death was respiratory failure brought on by pneumonia.
What Nelson was not told, until The Times reported it five days
later, was that the nurse assigned to keep constant watch over Mario
had not done so. She had silenced the alarm on his vital-signs
monitor, then failed to notice his heartbeat fading, according to
Los Angeles County health officials and the nurse's suspension
Nor was Nelson told that the nurse had allegedly falsified her son's
medical chart. According to county health officials, the nurse
indicated that she had found Mario stable at 6 p.m. more than an
hour after he had died.
"She took it in her hands to play God," said Nelson, who has sued
the county, which owns the hospital in Willowbroook, south of Watts.
Mario's death was no isolated incident. Three King/Drew patients,
all hooked up to monitors, died last year after nurses failed to
notice their declining vital signs, state and federal inspectors
The nursing department is often considered the heart of a hospital;
its failings alone can incapacitate the entire institution.
The frequency of lapses in King/Drew's nursing department suggests a
systemic problem, one that exceeds mere individual shortcomings.
In fact, a Times investigation found that such failings extend well
beyond nursing, to at least three other areas.
Mistakes and lax supervision at times have debilitated King/Drew's
pharmacy and doctor-training programs, which affect nearly every
patient. And the newspaper found the small but essential department
of orthopedic surgery to be crippled by employee misbehavior
absenteeism, profiteering, even the commission of felonies in off
The fault, hospital experts say, lies with the institution's overall
Unless leaders can identify and fix what is broken, a hospital
cannot operate safely, said Dr. Donald Berwick, president of the
Boston-based Institute for Healthcare Improvement. Otherwise, he
said, it's like insisting, "My car is fine except for the brakes."
Until recently, the county Board of Supervisors, King/Drew's
governing body, had balked at wholesale repairs. Over the years, as
the evidence piled up in audits, malpractice cases, internal memos
and reports from regulators, the board largely stood by, seemingly
paralyzed. The health department it oversees did little more.
"Fundamentally, someone has to step up to the plate and lead the
people out of the morass that they're in," said Dr. Kenneth W.
Kizer, president of the National Quality Forum, a nonprofit group
seeking to improve healthcare.
Orthopedic surgeons are the carpenters of medicine, called in to
repair limbs shattered by bullets or snapped in car wrecks. They
tend to the aching joints of the elderly and the torn ligaments of
the weekend warriors.
At King/Drew, they also quite often get into trouble.
It starts at the top.
Dr. Clarence Woods, who was removed as department chief this fall,
was twice faulted by county auditors for having little or no control
over his staff including surgeons and physician assistants who
often worked only when they wanted to.
Dr. William T. Long, the only other full-time orthopedic surgeon,
recently resigned after being threatened with dismissal for
allegedly falsifying his time cards and referring insured King/Drew
patients to his private practice at Centinela Hospital Medical
Center in Inglewood. Auditors found him performing surgeries and
seeing private patients at Centinela on at least five Fridays this
year when his time card indicated he was at King/Drew.
Long said the county dropped its allegations against him before he
resigned. "I was not found to be at fault for anything when I left
there," he said.
Department of Health Services officials said they could not comment
on personnel matters.
Dr. James K. Brannon, a surgeon and medical entrepreneur, is under
investigation by county auditors for alleged conflicts of interest.
Although he works just part time at King/Drew, the doctor over five
years ordered nearly $1 million in medical equipment for his
surgeries from a company he co-owns. The disposable items, used for
bone grafts, are far more expensive than the reusable devices
employed by most hospitals, orthopedic surgery experts told The
Brannon has denied wrongdoing, saying he ordered his company's
equipment with the full approval of the county.
The orthopedic surgery training program is so rife with troubles
that the county plans to phase it out at the urging of the group
that accredits physician-training programs nationwide.
In a recent letter to the hospital, the Accreditation Council for
Graduate Medical Education said King/Drew's orthopedic surgery
residents were badly selected and poorly trained.
Residents dissatisfied with the program told accreditors that they
were reluctant to complain because they felt intimidated by program
The department has other problems.
The performance of physician assistants, who treat patients and
prescribe medications under a doctor's guidance, is "terrible," said
a report the accreditation council sent to King/Drew last
summer. "These individuals are seen as unreliable and undependable,
frequently absent and often discourteous."
A county audit came to similar conclusions last year. In fact, then-
department chief Woods told auditors, King/Drew's own human
resources department had determined that physician assistants
were "running amok."
According to the audit, assistant Karen Theophile was reprimanded in
1999 for not responding when paged, in 2000 for not being available
when on call, in 2001 for not following directions and in 2002 for
skipping work without permission. Last year, auditors said they were
unable to verify when she worked because of her "inconsistent use of
the time clock."
Theophile declined to comment.
"What we have is a group of employees who don't come to work," Long
said at a meeting of physician assistants in April 2002, according
to the meeting's minutes. "Can't think of a single day when a PA has
been on time."
Woods told auditors in 2003 that he'd rather step down as chief than
figure out a solution. Supervising physician assistants, he
complained, "is like supervising children."
The failings of PAs extend beyond absenteeism.
For 5 1/2 months in 2002, physician assistant Andrew Josiah spent
his nights working at King/Drew and his days at the halfway house
where he was serving out a sentence for felony child abuse.
Josiah was convicted of trying to choke his 12-year-old son and then
dunking his head under water.
Woods knew all about it: By his own account, he signed the form
allowing Josiah to participate in the work-release program. The
hospital did not dismiss Josiah until July, six months after a state
licensing agency had put him on five years' probation.
Josiah did not return telephone calls seeking comment.
Woods, who still works as a surgeon at King/Drew, acknowledged that
he had been slow to discipline employees and naive to help Josiah.
But he said that under his watch the orthopedic surgery department
served patients well.
"We were productive," he said. "I think anybody you talk to could
attest to that that we were the hardest-working of the departments
In July 1999, Dr. Penelope Velasco, then 28, began training at
King/Drew to become an obstetrician/gynecologist.
By last year, the final one of her residency, she had been involved
in three malpractice suits.
In her first year, she was the primary surgeon during the caesarean
delivery of Lauryn Johnson, who suffered brain damage. In a lawsuit,
the baby's mother alleged that doctors performed the procedure too
late. The county settled the case for $2.5 million in July 2003.
In her second year, Velasco had trouble delivering a large baby who
became stuck in the birth canal, according to a subsequent lawsuit.
The baby's arm was left unusable. (Velasco was then working at
Riverside County Regional Medical Center as part of a training
rotation that King/Drew had arranged.)
The case against her and others was settled in September for
$375,000, according to the plaintiff's lawyer.
In her final year, Velasco performed elective surgery on 43-year-old
Sherry Ridley. During an operation to remove ovarian cysts, Velasco
stitched through Ridley's colon in error, according to Ridley's
medical records. Doctors did not notice the error for 12 days.
Ridley was ultimately overcome with infection and died.
Her family's lawsuit is pending.
Medical residents such as Velasco are expected to make mistakes,
experts say. But the experienced physicians overseeing them are
expected to catch the errors.
More than anything, Velasco's troubles highlight potentially
dangerous lapses in the supervision of King/Drew's doctor-training
programs, founded more than three decades ago to turn out talented
physicians to serve the nation's impoverished minority communities.
"The gynecology resident and attending surgeons in this case clearly
did not recognize what they were doing or had done," said Dr. ******
Gouge, director of surgical residency at New York University
Hospital, who reviewed Ridley's medical records for The Times. "They
thought that their stitches were fine."
Velasco said in an interview that she had received good supervision
during her King/Drew residency and had properly cared for patients.
She said she was aware of no evidence that she had stitched through
In any physician-training program, she said, "things will happen.
It's just the nature of medicine, the nature of life."
In the last two years, the national Accreditation Council for
Graduate Medical Education has ordered the hospital and its
affiliated medical school to close three of 18 training programs
in surgery, radiology and neonatology. Often, the group cites poor
Despite these sanctions, some residents continue to work with little
or no supervision. Just last month, a resident left a 20-inch-long
metal guide-wire inside a patient while trying to insert a catheter
into his leg. The error was not discovered until 13 days later, when
the wire was spotted precariously close to the patient's heart on a
routine X-ray, county health officials reported in a memo to the
Board of Supervisors .
An official at King/Drew's affiliated medical school, which runs the
residency programs, said they were moving "in a positive direction."
Ten have been fully accredited since January, including one that had
previously been on probation, said Walter Strong, vice president of
university affairs at Charles R. Drew University of Medicine and
Many current and former King/Drew trainees say they learned a great
deal from the variety of injuries they saw at the medical center.
"You can't buy the experience that I got at King," said Dr. Mary-
Anne Purtill, a 1997 surgery graduate who directs the trauma center
at the Medical College of Ohio in Toledo.
But King/Drew, by the county's own admission, often does not attract
top-tier minority residency candidates. And many residents, after
their training, fare worse than their peers on national specialty
King/Drew's academic problems can be compounded by its tolerance of
In 1999, for instance, the hospital hired Dr. Warren C. Lemons as a
resident in its family medicine program despite documented academic
problems. He had been forced to repeat his first year of a pediatric
residency in North Carolina and then left by mutual agreement with
officials without finishing the program.
At King/Drew, said a former staff psychologist responsible for
evaluating residents, Lemons displayed such odd and defensive
behavior that she kept notes about him on her daily calendar and
reported him to her superiors.
Lemons remained at King/Drew until 2001, when he was dismissed
because he failed to get a medical license from the state of
California as required.
Last February, Lemons returned unofficially. Security guards
caught him barricaded in an unused hospital room, with a former
King/Drew patient and videotaping equipment. The former patient, a
deaf and mute man, was zipping up his pants, and Lemons had his old
hospital ID, baby oil and restraints in his possession. Both men
were allowed to leave.
Months later, Lemons was arrested on suspicion of killing the man
during a sexual encounter in a Calexico hotel room. In a search,
police said, they found the dead man's King/Drew medical records and
140 videotapes, including some graphic images of naked male
The police investigation is still underway, and Lemons has not been
criminally charged. His attorney has said Lemons did nothing wrong.
In February 2003, federal agents raided the home of a low-level
pharmacy clerk, Eric Townsend, seizing 38,700 prescription pills he
had stolen from King/Drew and was selling from his garage.
Among the stash, agents found tablets to control depression,
schizophrenia, heartburn and high blood pressure, according to
Townsend's plea agreement. An informant told authorities he'd been
buying in bulk from the clerk for more than three years. The pills
seized in the raid, and 4,000 others acquired during a previous
undercover buy, were valued at about $150,000, authorities said.
Townsend was sentenced to five months in federal prison and ordered
to pay $30,000 in restitution to King/Drew.
The hospital's pharmacy director, Amy Gutierrez, acknowledged in an
interview that she hadn't been aware the drugs were missing until
she was contacted by the state Board of Pharmacy, months after
Townsend's sentencing. She said the department tightened security as
This was one of many significant failures in the department in the
last decade. It has been hobbled by haphazard supervision, staff
misconduct and venomous infighting, according to interviews,
lawsuits and county records. Employees have sued and countersued one
another, and even summoned county police to quell disputes.
What suffers is the department's core mission: delivering the right
drugs at the right time to patients.
In March, for example, federal inspectors confirmed a Times report
that a 46-year-old meningitis patient had been mistakenly given a
potent anti-cancer drug for four days. The drug, Gleevec, is used to
treat a form of leukemia.
The patient, William Watson, continued to fall victim to medication
errors even after the first mistakes were caught. Inspectors found
that nurses and pharmacists had failed to give him 25 doses of
medications ordered by doctors. Making matters worse, they had given
him 12 extra doses of one drug and one injection of an anti-
psychotic medication that was never ordered.
During their investigation, the inspectors pulling files randomly
discovered that pharmacists and nurses had mishandled the drug
treatment of nine other patients.
A stroke patient had to wait nearly five hours for a drug to help
prevent heart attacks and recurrent strokes, the inspectors' report
At one point, pharmacists refused to fill that patient's medication
order because a doctor had misspelled the drug's name. Later, an
inspector watched as two pharmacists within half an hour of each
other picked up the prescription, looked at it, then walked away
without arranging for its delivery. It is unknown whether the
patient suffered harm as a result.
In the August 2001 edition of Tech Talk, a short-lived internal
newsletter, pharmacy technician Derrick Evans warned of
an "alarming" number of medication errors.
"It's important that we don't forget who loses out if we do not do
our jobs to the best of our ability," he reminded his
colleagues. "The patients."
Current and former employees describe their bosses as misguided,
unqualified or, in at least one case, asleep. One pharmacy
technician recalled nervously filling prescriptions while the night
pharmacist pushed two chairs together, donned his slippers and slept
through his shift.
"He didn't check my calculations. He didn't check to see what I put
in my [IV] bags," said Cassandra Ellis-Woodson, a former King/Drew
pharmacy technician who quit in 2002. "There was just so much stuff
at that place . You couldn't focus on patient care."
County health leaders have said at various times in the last year
even after the cancer-drug mix-up that the pharmacy is one of the
better-functioning areas at King/Drew.
And Gutierrez, who has led the department for 10 years, said she was
not to blame for problems. She has tried to set high standards for
employees, she said, and that's why some don't like her. Also, she
said, the department struggles with a staffing shortage, which
forces the use of temporary workers.
Gutierrez said all hospital pharmacies make mistakes. "The answer to
a medication error is not always to point a finger at the bad
apple," she said. "You look at the system, and you look at a way to
improve the system so it doesn't recur."
But with some pharmacists at King/Drew, mistakes happen again and
One pharmacist from an agency that provides temporary workers,
Zenaida Joaquin, was reprimanded at least three times for mistakes
in the hospital's outpatient pharmacy in 2002 and 2003, county
hospital records show.
She allowed a patient to receive two vials of medication that were
prescribed to another patient with the same last name. She gave a
different patient three medications prescribed for someone else. And
she gave a third patient twice the ordered dose of Valium.
Joaquin said the outpatient pharmacy processes hundreds of orders a
day and does not have enough staff.
"I feel like I'm being made a scapegoat," she said. "There were
others who committed mistakes also."
Rona and Cynthia Millage were shocked to learn about the death of
Mario Nelson, the AIDS patient whose nurse had failed to notice his
heart faltering in October.
To them, it seemed the hospital had learned nothing at all from the
death of their mother, Robbie Bilbrew, 16 months earlier.
She too had been hooked to a cardiac monitor. Her condition too had
declined without anyone's noticing. Her nurse too had fabricated
chart entries in advance, a state investigation found.
The nurse, Elsa Ruiz, left the hospital the morning of Bilbrew's
death in July 2003, never to return. Ultimately she was fired for
abandoning her post.
Contacted by The Times, Ruiz declined to comment. She did, however,
admit to the state nursing board that she had repeatedly falsified
medical records and misrepresented events in the case, the board
said in a written accusation against her. The board's action is
Rona Millage said her mother, a 52-year-old former teacher's aide,
was in a hospital unit dedicated to patients who needed extra
nursing care. Yet she slipped away, alone and unnoticed.
"What was that nurse doing for all that time?" Millage
asked. "Didn't she care?"
It's a question the families of other patients, even some of the
hospital's own doctors, have asked as well. Some nurses at
King/Drew, they say, have lost or never had the sort of
compassion and commitment that draws people to the profession.
Hospital inspection reports, legal filings and personnel records
detail behavior by King/Drew nurses that seems not only callous, but
inconceivable even allowing for the pressures at a hospital with
an especially severe nursing shortage.
On several occasions in 1999, nurse Yvonne Cathey allegedly ordered
a janitor's aide to mix intravenous medications for critically ill
patients in the trauma intensive care unit. According to Civil
Service Commission records, the aide's job description restricted
her to "only the most unskilled duties" and required her only to
recognize "a limited number of two- and three-syllable words."
This year, the state nursing board stripped Cathey of her license
despite her denial of wrongdoing.
Between 1999 and March 2004, state inspectors cited King/Drew for
violating nursing standards more often than all but five of
California's approximately 450 hospitals.
Sometimes, according to inspection records, patients have languished
unattended by one nurse after another. A patient with gangrene of
the leg, kidney failure and a temperature of just above 90 degrees
shivered for 19 1/2 hours until his death without a special air-
heated blanket ordered by a doctor, said a 2004 federal inspection
report that did not name the patient.
Nurse after nurse reportedly noted the patient's low temperature but
ignored the directive, supplying only a light blanket.
Other times, the same nurse was involved in more than one serious
Wilma Walker was first suspended for three days in April when she
and other nurses were accused of giving the anti-cancer drug to
meningitis patient Watson, according to county records. Then, in
October, she was suspended again for alleged lapses in Mario
Nelson's care, including turning down his vital-signs monitor.
Walker has appealed her latest discipline to the Civil Service
Commission, denying the allegations.
Watson said the failings in his care were more than medically
harmful they were dehumanizing. Made incontinent by his
medications, he recalled mopping up his urine with his hospital
gown. The stench had become too much to bear.
"It's not really a great place to be when you're really sick," he
Cynthia Millage said the nurses and aides didn't take time for even
the most basic needs of her mother. Millage had to teach herself to
clean her mother's bedsores, even her breathing tube.
"It'd get all clogged and stuff," she said. "We had to do
In nursing, some dangerous practices were allowed and even
encouraged by the bosses. For instance, senior nursing managers
urged front-line nurses to minimize the severity of patients'
illnesses, a June county audit showed, because patients rated sicker
would require more nursing care.
The publicized troubles at King/Drew and a long contract dispute
with the county nurses' union have made hiring difficult and added
to the burden of those already on staff.
Despite the challenges, many King/Drew nurses say they do their best
to provide high-quality care. "We can't turn the patients away,"
said Ida Steverson, a surgical nurse, of the poor people King/Drew
serves. "They can't just get up and go to Cedars-Sinai" Medical
Center near Beverly Hills.
Some staffers remain on the job despite poor training and outright
Earlier this year, a consulting group tested King/Drew's nurses and
determined that at least one in five could not pass competency
Nursing expert Jean Ann Seago, who reviewed King/Drew's nursing
citations for The Times, said she'd seen rampant problems before
with one hospital unit or one rogue nurse, but never throughout an
"If it's sort of the general culture of the whole hospital, oh my
God," said Seago, director of the UC San Francisco nursing
administration program. "Somebody needs to get a grip on the
"This is an example of what happens when you just let things go on
and on," she said.