Officials at the District’s only public hospital failed to report to regulators key details about the death of a patient in the facility’s nursing home in August, an incident report submitted to the D.C. Department of Health shows.
The report, obtained by The Washington Post through a public records request, left out information about the case of 47-year-old Warren Webb that would likely have triggered an investigation of the long-term care unit at beleaguered United Medical Center in Southeast Washington.
The report did not disclose that Webb died, let alone that he repeatedly cried out for help, complained of shortness of breath and was left lying on the floor for at least 20 minutes by his nurses after he rolled out of bed — details that have been reported by The Post based on interviews with eyewitnesses and a time-stamped audio recording of the incident.
Instead, the Aug. 25 report states that Webb “was lower [sic] to the floor in sitting position when observed sliding out of his bed” and “was encouraged to wait for staff before attempting to get out of bed by himself.” In response to a question on the reporting form that asks whether medical treatment was necessary, hospital officials wrote, “No.”
The report’s omissions could intensify scrutiny of the hospital by D.C. lawmakers. Next week the D.C. Council is scheduled to vote on whether it will renew a $4.2 million contract for Veritas of Washington, a politically connected consulting firm that has been running UMC since last year.
Earlier this week, D.C. Council member Elissa Silverman (I-At Large) said she was “gravely concerned” about the safety of patients at UMC following a report in The Post about Webb’s case. On Thursday, council member Vincent C. Gray (D-Ward 7), chairman of the health committee, filed legislation that would end the Veritas contract.
The audio recording of the incident and interviews with three eyewitnesses show that Webb called for help and said “I can’t breathe,” but that his charge nurse, Christiana Ekwue, began arguing with his roommate and called a security guard.
Webb, whose diaper came loose as he rolled onto the floor of his bedroom, was left lying in his own waste and was not lifted back into bed for at least 20 minutes. At that point his nurses could not find a pulse and began trying to resuscitate him. Webb was transferred to the emergency room and pronounced dead of a heart attack slightly more than an hour after he began crying out.
A UMC spokeswoman said hospital officials, “under advice of counsel,” would not answer questions about the incident report. In response to previous questions about Webb’s case, the hospital issued a statement asserting that “timely notification to the appropriate regulatory and licensing bodies was provided.”
The D.C. Department of Health did not investigate the circumstances of Webb’s death after UMC’s report in August. The agency launched a probe based on the new information published by The Post.
Silverman said Thursday the hospital’s incident report does not match the audio recording published by The Post and appears to conflict with testimony at a Monday health committee hearing from UMC officials, who said they had performed an “exhaustive review” of Webb’s death and reported it accurately.
The report “is shocking to read, and does not seem to represent what actually happened, and is very distressing to me as a council member,” Silverman said. “And I think further explanation is needed from UMC.”
Toby S. Edelman, an attorney at the Center for Medicare Advocacy who reviewed the incident report at the request of The Post, said it omitted facts that would have led to regulatory scrutiny. She called the report “ridiculous.”
“It has very little connection to what really happened,” Edelman said.
Gerard Anderson, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, said hospital administrators often try to walk a “fine line” in reporting incidents between honesty and protecting their institution from legal risk.
The UMC report on Webb “seems to have broken the fine line” by leaving out vital information, particularly Webb’s complaints about shortness of breath, he said.
Anderson said the report also raises broader questions about the accuracy of UMC’s other reporting.
At the council’s health committee hearing Monday, Veritas employee and interim hospital chief executive David Boucrée said his predecessor, Luis Hernandez — also a Veritas employee — “conducted a full investigation to determine what happened,” in conjunction with UMC Chief Nursing Officer Maribel Torres.
Torres said she also filed a report with the D.C. Board of Nursing related to the incident. On Sept. 5, Torres made a complaint to the board about one of the nurses involved in Webb’s care immediately before his death, former UMC employee Peter Offor.
The complaint states that Offor, a licensed practical nurse, “did not respond to Warren Webb’s cry for help for approximately 1hr and 15mins” and that Webb “subsequently passed away.”
The time-stamped recording of the incident shows that Webb’s roommate, Gregory Gary, approached Offor at a nursing station and stated that Webb needed to be changed at 4:47 a.m. The charge nurse, Ekwue, then arrived at Webb’s room about three minutes later.
Webb began calling for help and saying he could not breathe as Ekwue entered his room. Amid his cries she can be heard arguing with Gary, who was pleading with her to do more to help him, and then conversing with a security guard who responded to the argument as Webb lay on the floor.
At about 5:08 a.m., Ekwue can be heard asking Offor for help lifting Webb back into bed. At about 5:23 a.m. Offor can be heard calling for a “crash cart,” a mobile stand that holds emergency lifesaving equipment, to revive Webb. Gary and a nursing assistant who was present, Mary Uwemedimo, both said that it as Offor who recognized the seriousness of Webb’s condition and called for help.
Had it not been for Offor, Gary said Thursday, Webb “would have died in the room” without even making it to the emergency room. “Mr. Pete went to work right away.”
Offor, who was fired from UMC, is contesting the nursing board complaint. In a written response to Torres’s allegation, he said that other nurses were at the back of the nursing station sleeping when Gary first asked for somebody to change Webb.
“I do think he’s being named as a scapegoat,” said Offor’s attorney, Neil B. Katz. “I can’t tell you what the reason is, because I don’t know yet.”