The probe, made public this week, found multiple shortcomings in the care provided at United Medical Center’s nursing home to Warren Webb, who died of a heart attack at the facility in August. Before his death, Webb called for help, fell out of his bed and was left on the floor for an extended period.
Inspectors concluded there was “no evidence that facility staff assessed [Webb] after he/she complained of not being able to breathe” and said hospital officials omitted key details about Webb’s death from an incident report they filed with the health department.
That report, among other things, left out the fact that Webb died and contained what one hospital employee told investigators was a false account of Webb being told at the incident’s conclusion to “wait for staff before attempting to get out of bed by himself.”
Regulators also found that the UMC nursing home did not have an instrument prepared to measure patients’ blood sugar in emergencies.
The health department began its probe in response to The Washington Post’s reporting on the circumstances surrounding Webb’s death.
Based on an audio recording of the incident and interviews with three eyewitnesses, The Post reported in October that Webb, despite crying out at least 25 times, was left on the floor for approximately 20 minutes by his charge nurse, Christiana Ekwue.
When Webb, 47, was finally lifted back into bed, his nurses were unable to find a pulse. He was transferred on a stretcher from the hospital’s 7th floor to its emergency room and was pronounced dead just after 6 a.m. on Aug. 25.
It is unclear what consequences, if any, hospital employees or managers could face as a result of the health department’s findings.
A UMC spokeswoman did not immediately respond to requests for comment.
Ekwue did not return calls for comment.
In a corrective plan submitted in response to the investigation, UMC officials said two employees were “disciplined” as a result of the hospital’s internal investigation of the incident, but provided no further details.
The plan also said the nursing home’s staff were being retrained on “respiratory assessments, treatments and documentation” and that unit managers are now required to conduct hourly rounds to monitor the condition of nursing home residents.
The plan states that medical staff would be trained on “accurate completion of incident reports” and requirements for notifying the health department of events within the hospital. All incident reports being sent to regulators are also now being reviewed by the nursing home administrator, hospital officials said.
Webb’s death came at a critical moment for UMC, as the hospital was under scrutiny for dangerous medical errors that led regulators to shut down its obstetrics ward in early August. Concerns about patient safety and mismanagement ultimately led the D.C. Council to vote in November against renewing a lucrative contract for Veritas of Washington, the consulting firm hired by the city to run the hospital.
This week, the hospital’s former chief medical officer filed a whistleblower lawsuit asserting that he was fired for testifying before the council about problems at UMC.
The health department’s investigation sheds light on at least one key question about Webb’s death: whether his nurses immediately assessed him when he first called out for help. Medical experts place a heavy emphasis on prompt assessments — including measurements of heart rate, respiration rate, blood pressure and blood-oxygen saturation — for patients who complain of shortness of breath.
Investigators found no documentation or other evidence that such an assessment took place for Webb until he was lifted back into bed after 20 minutes on the floor.
The report also raises questions about the hospital’s initial, inaccurate statements to the health department concerning Webb.
In testimony before the D.C. Council’s health committee in October, top hospital officials said that they had performed “an exhaustive review” of Webb’s case and reported it to the appropriate regulatory authorities.
However, the health department’s inspection found that the report on Webb was incomplete and that the hospital did not file another report — required whenever a nursing home resident is taken to the emergency room — until 11 days after Webb’s death. D.C. law requires that such reports be filed within 48 hours.
An unnamed hospital worker identified as “the person who reviews all incident reports for completeness and correctness” acknowledged errors in the incident report to health department investigators, saying it “should have contained the facts that the resident became unresponsive, CPR was started and that the resident was sent to the ER.”
The employee also said the statement about Webb being encouraged to ask for help when trying to get out of bed “is not right” and “should have been amended.”
When asked by investigators why the false statement about Webb was included, the hospital employee who originally typed up the report said, “I don’t know why I did that.”