Patient's death shows hospital lapses

By Sam Lagrone and Joseph Neff

Jun. 9, 2008 (McClatchy-Tribune Regional News delivered by Newstex) --

LOUISBURG -- William Bobbitt Paschall was a bad candidate for surgery, particularly given the poor care that investigators say awaited him at Franklin Regional Medical Center.

On the morning in December when he was admitted for elective knee surgery, Paschall, 76, had more pressing health problems: chest pain, shortness of breath and numbness in his left arm.

Paschall's symptoms suggested a severe heart condition, but doctors went ahead with the knee replacement anyway, according to his medical records and a federal investigation. The doctor who assumed care of Paschall after the operation said the surgical team did not inform him of Paschall's chest pains. The next day, the lab and nurses acted slowly to report a critical blood test showing he was on the verge of heart failure.

Paschall's heart stopped before doctors got the test results.

His death has led to three federal investigations at Franklin Regional. Beyond Paschall's case, investigators found that the hospital violated dozens of federal standards designed to keep patients safe.

According to two federal investigations, nurses and doctors failed to record critical medical information. The hospital allowed nurse anesthetists to work without required supervision. The third, as yet unpublished, investigation has found problems with the hospital's pharmaceutical and respiratory services, according to the Centers for Medicare and Medicaid Services in Atlanta.

Last week, federal regulators said they plan to take the rare action of cutting off the hospital's Medicaid and Medicare funding June 22.

The first investigation in March found an immediate and serious threat to patients' safety, said Jeff Horton, the acting director of the N.C. Division of Health Service Regulation. Conditions at the hospital posed a high risk of hurting patients, Horton said.

"That's very serious," he said.

The first two investigations and interviews show a hospital that kept poor track of patients' conditions and, in Paschall's case, allowed serious complications to go unreported and unnoticed.

Al Sayles, a Louisburg doctor and critic of the hospital, resigned his privileges in 2006 after citing what he described as a decline in patients' care.

"I got to the point I was constantly angry with the hospital, and how it was run," said Sayles, who first practiced at Franklin Regional in 1989. "Administration attempts to increase profit margins often resulted in short staffing, and it became a real effort to manage patients in the hospital."

The investigations have hurt Franklin Regional's attempt to relocate closer to Wake County.

Franklin Regional is a for-profit hospital owned since 1986 by Health Management Associates (NYSE:HMA) of Naples, Fla. Over a two-month period, Mike McNair, Franklin Regional's chief executive officer, declined requests for interviews to discuss the federal findings.

McNair issued a three-paragraph statement that said, in part:

"The committed staff of Franklin Regional Medical Center continues to work with CMS on our corrective action plans for quality service here at FRMC. We will continue to work diligently to satisfy their requirements. ... The hard work of our staff and physicians in addressing these concerns will assure that Franklin Regional continues to maintain the best care for our patients."

This report is based on interviews, medical records and federal reports.

Pills for chest pain

Except for a stint in the Army, William Paschall lived his entire life in Henderson, working as an electrician and maintenance man. On Dec. 4, he went to Franklin Regional for a pre-surgery evaluation that noted significant heart and lung problems. His surgeon obtained clearance for surgery from two of Paschall's doctors, including his cardiologist.

On Dec. 10, he woke at 4 a.m. with shortness of breath, numbness in his left arm and chest pain. He popped two nitroglycerin tablets before traveling to Louisburg for his 6 a.m. appointment to get his right knee replaced.

According to federal reports and his medical records, Paschall suffered from a host of health problems: heart trouble, diabetes, chronic obstructive lung disease, obesity and emphysema. He had only one kidney.

When Paschall arrived at the hospital, he told the nurse about taking medicine for chest pain, the nurse told investigators. Five minutes later, he was placed on oxygen and hooked up to an electrocardiograph to monitor his heart rate.

A nurse told federal investigators that the anesthesiologist, Steven J. Schwam, ordered the topical ointment Nitro-Bid to help increase the size of Paschall's blood vessels.

Investigators found that the anesthesiologist did not document Paschall's complaints or the Nitro-Bid treatment.

Under the federal standards, doctors and nurses are required to note any treatment or change in a patient's condition. Those notes are critical for subsequent doctors and nurses who oversee the patient's recovery.

There was no record that the nurse or Schwam told the surgeon, Clifford R. Wheeless III, of Paschall's heart trouble before surgery. Schwam and the nurse told investigators that they informed Wheeless before the surgery.

According to the investigation, Wheeless, one of Franklin Regional's two listed orthopedic surgeons, "stated more than three times" that he was not told of Paschall's chest pains until after the surgery.

Wheeless, contacted by phone, said he "had nothing to hide. ... I try to be a stand-up guy."

After agreeing to speak with The News & Observer, he did not respond to subsequent requests for an interview, citing patient privacy through an office worker.

Schwam declined to be interviewed. He issued a statement saying that he had an independent professor of anesthesiology review the record. The professor "confirmed that I provided Mr. Paschall medical care that meets the standards expected of a board-certified anesthesiologist in our state."

His lawyer declined to provide the professor's review.

Post-op trouble

The problems continued after Paschall left the operating room.

Paschall was not hooked up to a machine to monitor his pulse rate and oxygen levels during his recovery, something that Wheeless describes on his medical Web site as standard after knee surgery.

At 5:35 the next morning, staff drew a blood sample. The test showed a critically high level of potassium, a warning sign of heart and kidney failure.

The lab waited an hour after the test was completed, 7:16 a.m., to tell the nurse that his potassium level was dangerously high. There was no evidence the nurse informed the physician of the test results, the federal report found.

Half an hour later, Paschall was found with no pulse. Despite efforts to save him, Paschall died at 9:55, of a combination of cardiopulmonary and kidney failure, according to the death certificate signed by Wheeless, the surgeon.

Like many hospitals, Franklin Regional uses a "hospitalist," a doctor who stays at the hospital to care for admitted patients.

The hospitalist told investigators he didn't know until after Paschall was dead that he had any pre-surgery chest pain.

Screening problems

A complaint filed after Paschall's death brought federal investigators to the hospital in March. Typically, they would look both at the case in question and at a sample of similar cases to see whether they spot broader problems.

For example, federal rules require patients undergoing elective surgery to be screened within 30 days before their procedure to assess any potential risks. The investigators found problems with three other patients who received knee surgery:

--In January, a 74-year-old woman had an hourlong knee replacement procedure with no physical examination recorded before the surgery.

--Two days before the Centers for Medicare and Medicaid Services investigation, another patient underwent a knee replacement procedure with incomplete medical clearance.

--The same day, a 54-year-old woman underwent knee replacement surgery with a physical unsigned by a physician.

The federal focus on knee surgeries came as Franklin Regional performed more and more orthopedic procedures. Knee surgeries and other orthopedic operations make up a higher percentage of surgeries at Franklin Regional than at any other community hospital in the state.

In 2005 and 2006, Franklin Regional reported more than half its surgeries were either inpatient or outpatient orthopedic procedures -- behind only Presbyterian Orthopaedic Hospital in Charlotte and N.C. Specialty Hospital in Durham. On average, other hospitals in the state report that about 25 percent of their procedures are orthopedic.

Plans clouded

Paschall's death and the federal investigations have complicated Franklin Regional's multimillion-dollar expansion plans.

The hospital's chief executive, Brian Gwyn, was replaced in March. The new CEO, Mike McNair, told The Franklin Times, a twice-weekly newspaper in Louisburg, that Gwyn's departure was because of the report's findings.

Adam Searing, a health-care advocate with the N.C. Justice Center, contends that the focus on relocation could have compounded problems with patient care.

"The systems that are set up to catch the mistakes that people make are breaking down," Searing said.

Paschall's daughter, Mitzi Ross of Norlina in Warren County, said she had no idea that her father was such a poor candidate for surgery, but she trusted the doctors to know. Paschall's autopsy showed that some of his coronary arteries were almost completely blocked.

"It turned out," she said, "that he was a better candidate for a heart transplant than a knee replacement."

Newstex ID: KRTB-0038-25850123