My father died recently. Since his death, several family friends have had loved ones die. While it may seem coincidental, the more interesting coincidence is all these individuals were patients in the same hospital system when they died.
I have wrestled with the appropriate way to write this article because it deviates from the normal political op-ed that I have become accustomed to writing. The concern is it may come across as sour grapes, griping and moaning, being in the anger stage of the grieving process, or a plea for pity because it is personal in nature. It is none of those things. It is a disclosure of injustice against a family member leaving those behind confused and confounded. The read may be long, but the devil is in the details. Only the names of the facilities have been used to protect my family, avoid libel, and preserve the legal claim.
My father died due to medical negligence/malpractice and inadequate facility policy and procedure that resulted in his early death. Consulting lawyers informed our family little possibility exists to obtain justice for our deceased loved one under medical malpractice/wrongful death because of the lack of an autopsy. Moreover, victims’ families have two years from the date of injury to file legal action against the offending party. The law firm declined to take the case leaving our family searching for another attorney who may or may not take the case because another practice previously declined.
When collecting the medical records from the declining attorney’s office, I spoke with one of the lawyers’ secretary/legal assistant. I explained what was contained in the medical records, which she admitted she couldn’t open despite having the password provided on the disc, on the disc sleeve, and a post-it note, and informed her of a letter received from the hospital that indicated problems were identified as I had reported in the grievance filed resulting in corrective action being taken. She looked at me and said, “You have a case.”
In the State of Georgia, it is required to have an autopsy to determine the cause of death when pursuing legal action against a medical facility, staff, and/or doctor for malpractice/wrongful death. While an autopsy is needed to definitively prove the cause of death, it is possible to file legal action against the offender for medical malpractice/wrongful death without one – it just becomes more difficult. Our family did not have an autopsy performed because there was little consideration given to legal action at the time. Moreover, our religious beliefs precluded an autopsy except in cases of possible foul play and my Dad had requested throughout the years not to have an autopsy performed. Honoring his request and holding to our religious beliefs seemed appropriate at the time until we received the death certificate. The death certificate listed two diagnoses that my Dad did not have that caused respiratory failure then cardiac arrest – falsification of a legal document submitted to the State of Georgia.
After seeing the death certificate, we began to wonder what else could have been wrong. Medical records were obtained and reviewed. The discovery was shocking. Add to the fact the hospitalist admitted wrong-doing on two occasions and nursing staff failed to adequately monitor and respond to changes in my Dad’s condition, it became clear the hospital staff caused problems unrelated to his admitting diagnosis that lengthened his hospital stay and ultimately led to his death.
Our family filed a grievance with the hospital. After 45 days of review, the hospital concluded, “Through this examination process, needed actions were determined, assigned to the proper leaders, and appropriately addressed. We will continue to audit staff’s medical record documentation and in April will begin a 3-month focus [on] the importance on ensuring effective communication.”
While justice appears to be almost unreachable for our family on behalf of our deceased loved one via the legal system, it is hoped that justice can be served through continued pursuit of legal action, if an attorney can be located to take the case and public knowledge of the facility’s lack of quality care. More importantly, this is the honoring of his life by imparting truth in the treatment received at the offending facility in hopes others will look deeper at their loved ones’ care when at the facility.
My Dad, an Air Force veteran of the Korean War, died on February 9, 2019, at Piedmont Newton Hospital in Covington, GA; he was 83 years old. He left behind a wife, two daughters, three grandchildren, six great-grandchildren, three nephews and two nieces. A hard worker, James loved working on any type of motor, engine, hydraulics, and developed a hobby for woodworking. During his life, he worked in a foundry, on a dairy farm, in the oil fields in Venezuela, and operated an over the road transportation company driving an 18-wheeler. One could say he was a “jack of all trades” with the ability to fix anything.
He possessed strong values and principles that he passed along to his children and grandchildren. His word was his bond and he honored his word. He helped many a neighbor and friend who needed help without any thought of receiving anything in return. This earned him many fierce friends. A jokester and a man with a keen sense of humor, he frequently played many a trick on his children, who after a while, caught on to his pranks and learned to counter them. He was very protective and supportive of his family. Being the head of the household, he felt it his duty and responsibility to teach his posterity and protect them from harm.
His life was not always easy though. He was born with a clubfoot, which an inventive surgeon corrected without charge because the operation he performed had not been tried. Working around jet engines while in the Air Force left my Dad with progressive hearing loss resulting in his 100 percent disability from the Veteran’s Administration. He survived an automobile accident suffering only a crushed vertebrae and disc in his lower spine. In 2000, doctors found he had esophageal cancer – a cancer that only 10 percent of individuals survive. The treatments of radiation, chemotherapy and surgery to remove most of his esophagus and relocate his stomach over his right lung were successful. Due to the excellent care he received from physicians and hospitals who treated him, my Dad became an 18-year cancer survivor beating all the odds to recover completely.
However, his compromised right lung resulted in a fragile respiratory system. He suffered frequent bouts of pneumonia that required hospitalization. A preventive treatment regime prescribed by his pulmonologist reduced the incidences of pneumonia and hospitalization. While he retained his hair, the treatments caused extensive dentition problems resulting in removal of all the upper teeth and two-thirds of his lower teeth. The reduced capacity of his stomach meant he had to eat smaller frequent meals and caused a reduction in his water intake. He developed an enlarged prostate, hypercholesteremia (high blood cholesterol) and suffered from kidney stones and urinary tract infections. All were treated successfully.
In mid-year 2017, My Dad began complaining of dizziness and unsteadiness when walking. Initially, the doctor treated him for an inner ear infection; however, his symptoms continued to worsen as new symptoms developed – unsteady gait, lower extremity weakness, upper extremity tremors, complaints of visual changes, and imbalance. To continue to ambulate independently, he used a walker; however, there were times he required a wheelchair. In December of 2017, a CAT scan revealed a lesion near the cerebellum above the brain stem. Determined to be inoperable, recommended radiation treatments were completed.
For the next year, my Dad worked to regain his steady gate and strength through physical therapy and rehabilitation. However, these efforts were unsuccessful. He continued to need assistive devices for ambulation and assistance when navigating stairs and long distances. For months, treating physicians declared the lesions to be dissipating; but, they determined “scabbing” to be the cause of his continued symptoms. Medication to decrease the inflammation in the brain area helped with additional symptoms of slurred speech and blurry vision. The bilateral upper extremity tremors were treated with anti-seizure medication. Eventually, my Dad became bedbound except for bathroom privileges requiring the assistance of one individual. He suffered several falls. At one point, it was necessary to have paramedics assist to get him up from the floor after suffering a fall.
Starting in November of 2018, my Dad stopped eating and drinking. The oncologist prescribed medication to stimulate his appetite but it produced little results. He lost a significant amount of weight, going from 185 to 155 pounds upon his last physician visit. We tried hemp oil atomizers in hopes of stimulating his appetite. My mom created a recipe for high protein, high calorie, and high nutrient shakes to supplement what little he ate. These measures worked for a short period then he would revert to not eating.
His bedbound status resulted in the placement of a urinary catheter due to his continued prostate problems. The catheter was replaced frequently because of leaking around the bulb, sediment occluding the catheter, and complaints of pain. The frequent changes caused excessive bleeding in the bladder, which resulted in blood clots that contributed to catheter occlusion. Upon consultation with all physicians involved in his care, the decision was made to place a suprapubic catheter for long-term management of urinary difficulties and insertion of a J-tube to provide nutritional supplements due to refusal to eat and drink – commonly diagnoses as failure to thrive.
In January of 2019, my Dad was admitted to Piedmont Rockdale Hospital in Conyers, Georgia, for suprapubic catheter and J-tube placement. It was decided to insert a PICC line for use in case of fluid and antibiotic treatment needs. In order for Medicare and supplemental insurance to pay for the J-tube placement, the surgeon used the diagnosis of “dysphagia” – difficulty swallowing. Dad never experienced dysphagia with his esophageal cancer nor after treatment. The J-tube was placed because the oncologist believed Dad was experiencing failure to thrive – insurance does not pay for stomach tubes and feedings for failure to thrive. Tube feedings were started and Dad began eating a solid regular diet without difficulty despite his upper dentition loss and loss of 2/3 of his lower dentition.
After being in the hospital for one week, he developed pneumonia. The floor hospitalist diagnosed “aspiration pneumonia”. However, the admitting hospitalist did not continue his preventive pulmonary treatment for pneumonia and it was postulated he suffered atelectasis (collapsed lung) during surgery. Per his oncologist, aspiration pneumonia involves the right lung and Dad’s issue was the left lung. Several x-rays confirmed left lung involvement. A treatment regime was started. During his stay, my Dad required Oxygen at 2 liters/min to maintain pulse oxygen saturation above 90 percent. Unfortunately, he would need to continue Oxygen usage upon discharge.
The failure of the hospitalists to continue his pneumonia prevention regimen resulted in an additional two-week stay in the hospital, Oxygen usage, and Oxygen dependency. We had no idea his pneumonia prevention regimen was missed. We had informed the admitting doctor in the emergency room of the need for its continuation since Dad had a fragile respiratory system. When attempting to discuss this with the hospitalist who diagnosed aspiration pneumonia and ordered speech therapy for dysphagia, which Dad did not have or ever have, the hospitalist interrupted abruptly, refusing to consider the extensive knowledge we as a family have regarding his condition. We lodged a complaint with the hospital administration.
After three weeks passed, Piedmont Rockdale Hospital determined it was appropriate for Dad to be discharged. X-ray films revealed his pneumonia was not resolved; however, Medicare took the recommendation of a hospitalist who had only seen him twice and one, again, who failed to understand the fragility of his respiratory system. Dad was discharged to home with Oxygen at 2 liters/min, tube feedings, oral antibiotics for pneumonia treatment, and hospice care to provide my mother and I assistance with his increasing care needs. At this point, Dad could barely move his legs and had little strength to assist in turning and repositioning.
The incorrect diagnoses of aspiration pneumonia, resolved while at home, and dysphagia will play a large part in the problems experienced in his final hospitalization and would appear on the death certificate with dysphagia linked to esophageal cancer, resolved over 18 years ago, as an active diagnosis. There was no mention of his brain tumor(s) at all.
After being discharged to home, we continued his routine medication and pulmonary regimen – Mucinex and nebulizer treatments. His tube feedings were done at night for nutrition while encouraging eating of solid food during the day. The oral antibiotic treatment for pneumonia was completed. His PICC line was flushed daily and his catheter bag emptied twice per day. For a few days, he ate a bit during the day; but, he reverted to refusing to eat again. Additional water was provided through the J-tube in order to meet hydration needs. During the ten days he was at home, he developed a swollen abdomen with abdominal pain and low urine output, with the color of the urine appearing dark amber like strong tea and sandy-looking sediment appearing in the tube. The hospice nurse evaluated his condition and the determination was made to admit him to the hospital. Piedmont Newton Hospital was chosen by my mom. He was transported to Piedmont Newton Hospital emergency room by ambulance on February 4, 2019.
Upon arrival to Piedmont Newton Hospital ER, several diagnostic tests were completed. My Dad was diagnosed with diverticulitis and a fecal impaction, despite receiving treatment for constipation while at home and having four bowel movements in one day. The ER continued his oxygen at 2 liters/min and started fluids, antibiotics for the diverticulitis, and treatment for fecal impaction. He was admitted to the fourth floor several hours later. His tube feedings were continued during the night.
That evening, his oxygen usage doubled from 2-3 liters/min. to 5-6 liters/min. By the time I arrived to relieve my mom the next day, February 5th, Dad’s Oxygen usage had increased to 6-8 liters/min. I questioned this. Mom didn’t know why his Oxygen usage was increasing except in response to his decreased pulse oxygen (pulse-ox) readings. On the treatment board, someone had written, “? volume overload”. My mom stated the admitting hospitalist had written it on the treatment board along with diverticulitis and fecal impaction. Again, I asked if anyone had mentioned what had caused the reduction in Dad’s pulse-ox readings. Mom told me that no one had said anything to her about it. She indicated the staff had continued his pneumonia prevention regimen. During my stay with him, his Oxygen usage increased again to 10 liters/min.
After consulting with my sister who possesses a doctorate in Pharmacy, it was determined a change in antibiotic was needed. Dad had been receiving Levoquin, which is damaging to knee joints. With trying to move him and his decreased ability to assist, the change in antibiotic was requested in hopes of avoiding a complication of a damaged knee joint while turning and repositioning. The hospital staff honored the request for a change in antibiotics. Morphine and Ativan had been ordered to help Dad with pain from diverticulitis, assist with abating his difficulty breathing, and combat increasing anxiety and agitation.
When the floor hospitalist visited the next day, February 6th, he stated he was worried about my Dad’s deteriorating respiratory status and increase Oxygen usage. The goal, according to the hospitalist, was to decrease Dad’s Oxygen usage in order for him to return home. Around mid-day, Dad’s blood pressure became extremely low when taken by staff with the machine. When I requested a manual blood pressure, the hospital staff gave me a “deer in the headlight look” and the nurse who performed the manual blood pressure made several errors. Upon my request, Mom brought my equipment in order for me to monitor his blood pressure and assess Dad’s lungs.
His blood pressure was low – 80s/50s, with his lungs having crackles (soda pop fizz sounds) in the left upper lung and coarser crackles over the right upper side near the bronchial bifurcation. On both sides, Dad’s lung sounds were decreased. For the right lung, it was normal to hear decreased sounds because his stomach sat over his right lung causing diminished capacity. While the hospitalist expressed worry about his respiratory status and increased Oxygen usage, there were no treatment interventions implemented or diagnostic tests ordered to determine why Dad’s respiratory status had deteriorated, except the board notation of volume overload. The next question became how did Dad get volume overload.
After coming home from staying with Dad, I began intensive research into causes of deteriorating respiratory status and increased Oxygen usage. Since it had been a while in dealing with cardiac/pulmonary issues, I had to be certain of my hypothesis. Besides volume overload, the next possibility was decreased cardiac function – congestive heart failure. A diagnostic test to determine cardiac ejection fraction would confirm or deny this hypothesis. Moreover, a consultation with Dad’s pulmonologist needed to occur to alter his respiratory treatments. In the meantime, fluid could be drawn off through the use of a powerful diuretic.
Mom called in the middle of the night to inform me that the doctor had ordered Lasix, but she didn’t know why. We discussed the deterioration of his respiratory status, the sound of fluid over the lung fields, and his increased Oxygen usage as possible reasons for the Lasix. I questioned whether anyone had mentioned Dad’s blood potassium level since Lasix reduces blood potassium levels. She stated no one had mentioned his potassium level. We conferenced with my sister and agreed to administer the Lasix regardless of his potassium level and request potassium supplement be given.
Mom called me again within the hour reporting several problems with the nurse – nurse stated Lasix order expired and could not contact a hospitalist; nurse did not know how to administer tube feeding; and, nurse appeared unknowledgeable about decreasing respiratory status. I was readying to return to hospital and Mom stated to get some rest. I told her I would take care of these issues in the morning.
Upon arrival at the hospital, February 7th, the hospitalist was visiting. Dad’s Oxygen usage had increased to the maximum according to the device. I, aggressively, pushed the hospitalist with the theory of Dad’s compromised respiratory system being due to decreased cardiac ejection fraction and need for echocardiogram, consult with pulmonologist, and more aggressive treatment. The hospitalist stated a BMP was performed and was normal. Immediately, I told him that was not the same thing. He admitted twice, after I repeated the need for additional tests to determine the cause of his deteriorating respiratory status, he had volume overloaded my Dad with fluid which caused the deterioration of his respiratory status. We learned Dad’s potassium level the night before was low at 3.2 but had increased to 4.0 with the early AM blood tests. Hospitalist agreed to proposed treatment plan with administration of Lasix.
In speaking with my Mom, she stated she and the hospitalist had a heated discussion. She stated she requested that she be informed of changes in Dad’s medical status and informed of reasons for treatments. She said the hospitalist stated he had twenty patients and could not inform patients/family of reasons for treatment or changes in medical status. I lodged a complaint with the nurse supervisor against the hospitalist and the night nurse.
The pulmonologist changed the respiratory treatment medication and regimen. He ordered Lasix, Solumedrol, chest percussion, and increase in Mucinex to loosen secretions. Dad’s blood pressure remained low and no improvement was made in his respiratory status.
To make this long story shorter, the needed interventions to combat a complication caused by the hospitalist and hospital staff through lack of reacting to significant changes in my Dad’s respiratory status were too little too late – my Dad died on February 9th. His death certificate listed “chronic dysphagia from esophageal cancer resulting in aspiration pneumonia caused respiratory failure producing cardiac arrest.” Remember, Dad refused to eat or drink by mouth, never had dysphagia, his esophageal cancer was resolved in 2000, and his pneumonia occurring from the previous hospitalization was due to atelectasis, not aspiration.
A review of the medical records revealed the hospital staff had administered 2000 ml of fluid over 30 minutes in the emergency room; then, another 1500 ml of fluid was administered on the floor. The doubling of his Oxygen usage occurred only a few hours after arriving on the floor. There was no intervention by the nursing staff at that point.
The medical records revealed that nursing staff charted his Oxygen usage at various levels ranging from six to nine over the course of his stay but never coincided with respiratory therapy records or what was observed in the room. Diagnoses were picked up by Piedmont Newton Hospital hospitalists that were irrelevant, made by other physicians during a previous hospital stay at a related Piedmont Hospital, and resulted in inadequate medical care. What should have been a 1 – 2-day hospital stay for diverticulitis and fecal impaction turned into a 5-day stay resulting in the death of my Dad.
Other problems occurred during his stay. The nurses failed to properly flush Dad’s PICC line resulting in both lumens occluding needing intervention to open the lines with Heparin. And, several nurses violated the aseptic technique when working with his PICC line. After notifying the nurses and the nurse supervisor of poor technique and care, the offending nurses refused to interact with me or my Mom to update us on any care Dad received.
We are in the process of trying to find another lawyer – one who specializes in negligence, to take our case, which we believe can be proven through the medical record, our documentation and observations, and the result of the hospital investigation stating that problems existed that were being rectified. With the State of Georgia still clinging to remnants of the “good ole boy” network where members protect their own, our family may have to scour the entire State of Georgia to find an attorney, plus one that will take the case on contingency since my mother does not have funds to place an attorney on retainer. Moreover, my Dad, as well as all patients who die under medical care, deserves to have a death certificate that is factual and accurate concerning the causes of death – not one contrived, falsified or invented. My Dad deserves justice. Hopefully, we can obtain justice through the legal system. If not, the public should be aware of the circumstances occurring at Piedmont Newton Hospital in order to effect a more rapid change, monitor closely their family member’s condition while hospitalized, question all care provided by staff and hospitalists, and be mindful of the law should one’s family member die under questionable circumstances unrelated to an admitting diagnosis or one under which the individual possesses.
Article posted with permission from Freedom Outpost
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