Broken Bed Alarm Blamed for UCSD Walkaway Patient's Death

Broken Bed Alarm Blamed for Walkaway Patient's Death
Thomas Vera died after he became disoriented and walked away from his hospital room at UCSD Medical Center in May
By Steven Luke
NBC 7 San Diego
Sep 15, 2014

California Department of Health and Human Services records obtained by NBC 7 shed new light on what went wrong inside UCSD Medical Center when a disoriented patient walked away from his supervised room into a nearby canyon.

The [May 2013] lapse in hospital security led to a tragic search which ended when ...Thomas Vera’s body was found [several] days later less than a mile from the hospital entrance in Palm Canyon.

Family blames the hospital for allowing 58-year-old Thomas Vera, suffering severe head and neck injuries as well as [delusions], to leave the facility...

According to the CHHS investigation, Vera’s bed alarm never sounded. Vera was under video surveillance, and when nurses were notified, the report states they “attempted to contact security by paging security twice with no response and then pushing the panic button twice with no response.”

The panic button was “broken for 8 days,” according to the report.

State inspectors said the hospital failed to routinely test the buttons and failed to repair them when broken.

Prior to Vera’s disappearance, the most recent test had revealed more than 1 out of every 4 panic buttons at UCSD’s two main hospitals didn’t work.

“That’s incomprehensible to me. This is a big time, generally well thought of medical facility, and it’s like clown school” said legal expert Joel Brant, an attorney who specialized in elder care law.

[Maura Larkins comment: I don't believe they're clowns. The buttons were not a priority. UCSD pays huge amounts of money to maintain the equipment it wants to keep maintained. Were the walkaway patients paying full price? Were they a drain on UCSD financially?]

UC San Diego Health Sciences director of communications Jacqueline Carr released this statement in response to the incident:

“UC San Diego Health System underwent extensive internal and external investigations to identify the reasons that led to this tragic event...”

Fifteen months after the incident, CHHS says no fine or penalty has been issued as a result of the mishap...

Read more here.


Missing Hospital Patient's Body Found in Canyon: Officials
By Monica Garske and Dave Summers
NBCSanDiego
Jun 1, 2013

The body of a missing hospital patient was discovered by search and rescue officials in a canyon Friday evening after an extensive search.

Chula Vista resident Thomas Vera, 58, had been missing since Monday. For the last several weeks, he had been a patient at the UCSD Medical Center.

Vera was admitted to the hospital after falling down the stairs at his home. He suffered a concussion and broken collar bone, according to his family, and was awaiting surgery...

A QUESTION OF PRIORITIES: Profits, Short Staffing, and the Shortchanging of Patient Care at UC Medical Centers

The public sees University of California Medical Centers as premier, world-class facilities. We rely upon them when our loved ones face the most serious illnesses because we expect them to provide the highest level of care. With the UC Medical System earning $6.9 billion in operating revenues and hundreds of millions in profits, it has the resources to do just that.

But recently, patient care advocates have witnessed something else: administrative decisions that prioritize UC’s profit margins over patients’ health. These decisions reflect a shift in values that reached a tipping point with a system-wide policy in 2011 that decentralized UC budget practices, and turned each medical center into an independent profit center.

This culture change is evidenced by a sharp rise in management salaries and compensation, excessive management costs, and unprecedented borrowing to construct new buildings.

Since 2009, management at UC Medical Centers has grown by 38 percent, adding $100 million to the annual payroll cost of management.

Debt service payments have almost quadrupled since 2006.

This diversion of patient care dollars results in management’s need to capture “efficiencies” to bolster profit margins.

While “efficiencies” can be positive, they can also have serious negative consequences. Often taking the form of aggressive cost-cutting measures, some translate into chronic short staffing, over scheduling of operating rooms, prioritizing “VIP” patients over everyone else, shortchanging charity care, and outsourcing essential services.

These degrade the medical centers’ core mission...

The State of California provides significant funding for the University’s Health System. In the fiscal year 2012-2013, it will provide approximately $300 million in public dollars for health sciences instruction....[Read more here.]