In the previous article at Freedom Outpost, "Georgia: Justice Denied for Family Who Lost Loved One to Malpractice", the details and circumstances surrounding my Dad's death caused by the negligence/malpractice of the staff at Piedmont Newton Hospital in Covington, Georgia. It appears that justice will not be served via the legal system to hold individuals accountable for the inaccurate, sloppy medical record keeping that hampered his care, the assumptions made by medical professionals without adequate physical assessments performed, the delay in treating the fluid volume overload caused by the staff, and the falsification of the death certificate, as well as other issues occurring during his stay for diverticulitis/fecal impaction. Therefore, those involved in this process and their action or inaction will be exposed in order that other individuals will think twice before taking their family member to Piedmont Newton Hospital.
My Dad, James L. Verhine, Jr., was admitted to Piedmont Newton Hospital on February 4, 2019, with the diagnoses of diverticulitis and fecal impaction; then, he died on February 9, 2019, with the reasons on the death certificate listed as: (D) chronic dysphagia from esophageal cancer with approximate time from onset to death as years; (C) aspiration pneumonia with approximate time from onset to death as 8 – 10 days; (B) respiratory failure with approximate time from onset to death as 4 hours; (A) cardiac arrest with approximate time from onset to death as 1 hour. He was diagnosed with an inoperable brain mass, malignant, in 2017, in the cerebellum; but, nothing was mentioned on the death certificate as that contributing to his death.
Falsification of the Death Certificate
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Dr. Binh Nguyen (pronounced "Winn) completed and signed the death certificate (Exhibit 1) listing the causes as indicated previously. However, diagnostic tests during hospitalization at Piedmont Newton Hospital indicate my Dad's lungs were clear on admission (Exhibit 2 and 3) with subsequent procedures indicating his lungs displayed atelectasis (Exhibit 4 and 5). It was hypothesized he may have had aspiration event; but, he had been refusing to eat or drink while in the hospital and diagnostic tests were indicative of atelectasis, not aspiration. His saliva production was decreased causing the inside of his mouth to develop "crusts" on the palate.
One cannot aspirate when one is not eating or drinking. Moreover, with saliva production low, it would be difficult to aspirate enough to cause aspiration pneumonia leading to respiratory failure.
The records indicate my Dad was administered 2,000 ml of normal saline in the emergency department followed by 1,500 ml after arriving in his room on the fourth floor (Exhibit 6) as ordered by Dr. Uday Tata. Upon admission, his oxygen usage was 2 liters/min (Exhibit 7). Roughly 12 hours later, my Dad's oxygen usage increased to 5 liters/min (Exhibit 8) and by early AM, 03:35 2/5/2019, it doubled again to 12 liters/min (Exhibit 9). The only difference was the bolus of 2,000 ml and the 1,500 ml of normal saline intravenously. The diverticulitis and fecal impaction had crowded his lungs but his respiratory system and oxygen usage were stable upon admission.
So, why would a doctor take an old diagnosis that was resolved and use a diagnosis that was not confirmed by diagnostic tests on a death certificate in slots D and C as contributing to respiratory failure? Wouldn't it have made more sense to use atelectasis, which was indicated in the diagnostic tests, and the diverticulitis and fecal impaction limiting lung expansion, or use the malignant brain tumor and atelectasis in slots D and C? The only reason to use an old resolved diagnosis and a "possible" diagnosis of "aspiration pneumonia" would be to cover for the fluid volume overload suspected in compromising Dad's lung function in such a short period of time. But, Dr. Nguyen resolved the fluid volume overload on the very day it was added into the system, which was 2/4/2019 (Exhibit 11). There is doubt this was resolved.
One of the hospital nursing supervisors, Jill Treadwell, and the Patient Care Experience manager, Michael Todd, were made aware of the fluid volume overload, the fact that Dr. Uday Tata admitted twice he had fluid overloaded my Dad, and the PCE manager was notified of the false information on the death certificate. Unfortunately, the hospital administration has not indicated they would move to get the doctor to correct the death certificate corrected; but a letter was received stating there were problems found related to our complaints and actions were being taken (Exhibit 12). Calls were made to the coroner of Newton County, Tommy Davis, but the office of the coroner has yet to return my calls.
Both Drs. Uday Tata and Binh Nguyen are being reported to the Georgia Medical Composite Board for unprofessional conduct – Nguyen for falsifying a death certificate and Uday Tata for overloading my Dad with fluid but not informing the family until three days after the fact and failing to keep family members apprised of all treatment regimens and changes.
Computerized Record Software Encourages "copy/paste" assessments
At no point did any staff member or doctor take a complete history from the family nor did anyone perform a complete physical assessment. If they had, staff and doctors would have known that Dad's esophageal cancer with resection and gastric pull through was completed in 2000, he had been in remission since, and had experienced no dysphagia other than prior to the diagnosis of esophageal cancer in 2000. Additionally, it would have been known the diagnosis of dysphagia, appearing on the medical record as added by Dr. Andy Harper, general surgeon, was used in order for insurance to pay the claim for the J-tube and feedings. Medicare and private insurance do not pay for the procedure for the diagnosis failure to thrive. Moreover, they would have known his pneumonia from the January hospitalization was resolved, determined to be caused by atelectasis from J-tube insertion surgery, discovered he had not been eating and drinking for several days prior to presentation at Piedmont Newton Hospital, and the family were very familiar with signs and symptoms of aspiration, reporting he did not exhibit any aspiration symptoms.
Instead, it appears staff relied on the computerized medical records to "discern" a history and physical. The problem with this is all Piedmont healthcare facilities are connected, resulting in diagnoses from all admissions to appear on the "problem/diagnosis list". And, rarely are "possible" diagnoses removed or indicated as being wrong once diagnostic tests determine otherwise (Exhibit 10 and 11). And, past/resolved diagnoses can be moved to "active" status.
When it comes to assessments and documentation, flow sheets indicated nurses were charting an incorrect oxygen usage for the days after the increase to 12 liter/min. (see full record at the end) How is proper carea given when incorrect information is being recorded in the patient record?
The nurses will be reported to the Georgia Board of Nursing for their failure to document accurately (there are many to report), which is an indication of inadequate assessments being performed throughout the shifts, resulting in compromised care.
A complaint will be filed with the Georgia Department of Community Health, Office of Regulatory Service against Piedmont Newton Hospital because their medical record software encourages "copy and paste" information, discourages appropriate history and physical assessments on admission and throughout the hospital stay, and allowing the use of diagnoses resolved over 10 years ago to be presented as "active". Moreover, the philosophy of the hospitalist, Dr. Uday Tata, at Piedmont Newton Hospital as well as other hospitalists at Piedmont Rockdale Hospital appears to be: if it's in the computer, that is what is regardless of what the family reports; and, whatever the family reports should be discounted because we who have seen the patient 5 minutes know more than family members who have cared for the patient for years. More simply put, the computer record is always right.
Negligence and Medical Malpractice
There are questions surrounding the administration of 2,000 ml of fluid bolus (as fast as possible) to an individual 83 years old, with a fragile respiratory system due to past frequent bouts of pneumonia and most recently atelectasis from a prior hospitalization, and decreased urine output from malnutrition due to refusal to eat and drink, and an additional administration of 1,500 ml of fluid once admitted to the hospital floor. Compromised individuals can experience fluid volume overload with 1,000 ml of fluid and some healthy individuals can enter volume overload status with the administration of 2,000 ml of fluid. So, was care being provided based upon the individual or upon a set standard of protocols/policies and procedures?
A source at Piedmont Rockdale Hospital had relayed that the hospital system uses an established policy/protocol for identified diagnosis. Each step has to be followed and documented. If a step is not followed for any reason, extensive documentation for not following the protocol is required. According to this source, these protocols/policies do not take into consideration age, medical status, complexity of multiple diagnoses, medications or compromised systems based on past surgeries, procedures or illnesses. It would appear the hospital promotes "treatment by protocol" instead of individualized treatment based on thorough patient assessments, evaluations, histories and physicals. Moreover, if the documentation does not include all steps, it can cause the system to flag a patient for early discharge.
These protocols also recommend a "pat" treatment of certain antibiotics that are not necessarily the best antibiotics for a specific infection. This can result in the development of bacterial resistance to those antibiotics. This was postulated by the hospice physician when Dad arrived home from his stay at Piedmont Rockdale Hospital because the pneumonia from atelectasis had not fully resolved.
Based on this information, hospitalists with heavy patient loads could overlook certain "steps" in the protocol thereby causing harm to the patient, flag the patient for early discharge, and result in readmission within 30 days or sooner.
Throughout the record, the hospitalists, Nguyen and Tata, latched onto diagnoses that were old, resolved or used to ensure payment for services placed into the record by other physicians instead of performing adequate histories and physicals for the current hospitalization. It is important to know past medical history in order to watch for any reoccurrence. But, this practice resulted in harm in the case of my Dad. Dr. Tata ordered a consult with pulmonology based on dysphagia resulting in an aspiration event. However, diagnostic tests indicated atelectasis, which the pulmonologist, Dr. David Snyder, suspected. How many other patients and their families have experienced this but not known it?
Dr. Snyder's office was called and asked about the diagnosis of dysphagia, why it was used when Dad did not have dysphagia, and the correct diagnosis needed to be used. Dr. Snyder's staff indicated that Dr. Snyder could not change the diagnosis in the computerized medical record because it was finalized; and, Dr. Snyder had to use the diagnosis for which he had been called in for consultation.
Granted, some families are not as knowledgeable or have the extensive medical backgrounds present in our family, meaning the hospitalist would have to rely heavily on the computerized medical record. But, when family members do, as in our case, our knowledge was negated for some reason that could be described as ego and the computerized medical record became the "expert".
Another practice that has been lost is the nursing admission history, physical and assessment. In the past, this was an invaluable tool for all medical professionals involved in the patient's care. Between the physician's history/physical and the nursing admission assessment/history and physical, a complete picture of the individual's current and past health status is gathered resulting in better patient care. It was evident staff failed in assessing my Dad properly because charting indicated normal dentition and gums when he had no upper teeth and 2/3 of his lower teeth were missing. Only one time did a nurse record he had missing teeth.
Hospitalists, particularly Dr. Uday Tata, at Piedmont Newton Hospital are not adequately discussing medical diagnoses, treatment plans, rationales for those treatment plans, and prognoses with the patient or the patient's family. This is essential in order to maintain informed consent for services. Dr. Uday Tata explained his lack of keeping the family informed was due to "having 20 patients" that doesn't allow him time to explain everything.
The nursing staff was guilty of the same infraction – failing to inform the family of treatments and orders along with pertinent lab results when the hospitalist did not. This was evident when a Lasix treatment was ordered, my mother did not know why, neither did the nurse, and the nurse did not know Dad's last lab result for Potassium, which is critical when administering Lasix. Because of the lack of information, my Mom refused the Lasix treatment initially, but consented later after much discussion with knowledgeable family members. Unfortunately, the nurse informed her the order had expired and a hospitalist could not be reached during the night, which was not accurate. This confusion delayed treatment. However, because of the delayed response by the hospitalist to address Dad's declining respiratory status and increase oxygen usage, there is a belief these measures were too late in reversing the course of impending respiratory failure.
If anyone chooses to use Piedmont Newton Hospital for a family member or themselves, there are several proactive interventions you should take to ensure safe care.
- Record everything with your cell phone or other device;
- Request to see the medical record on file and request to see each day's care provided by physicians, nurses, ancillary staff and pertinent flow sheets;
- Ask questions and refuse any treatments when staff cannot provide adequate explanations for that treatment or if the treatment seems out of the ordinary based upon admission diagnoses;
- Have a family member or someone you trust stay with you or your family member during the entire hospital stay; and
- Do not hesitate to contact a nurse supervisor (one is available 24/7) and the Patient Care Experience manager with any issue encountered immediately.
After discharge, request a copy of the complete medical record and examine it for accuracy. Better yet, use another facility if possible. Despite the extensive medical knowledge we possessed, it was not enough to thwart the unprofessional behavior of others.
Our family will never know whether more prompt action and attention to my Dad's changing status would have made a difference. We have the belief that it would have made a difference considering the multitude of failures at every critical point. While Dad was considered terminal with a malignant brain tumor, the rapidity with which his condition deteriorated after treatment with fluids suggests he might have lived longer once the diverticulitis and fecal impaction were resolved.Don't forget to Like Freedom Outpost on Facebook, Google Plus, & Twitter. You can also get Freedom Outpost delivered to your Amazon Kindle device here.