Report: Beebe let lock problem linger

2011 investigation put Beebe accreditation temporarily on hold
October 19, 2012
State investigators found faulty door locks at Beebe Medical Center in an unannounced visit following an incident in which a girl died. SOURCE FILE

A state inspection of Beebe Medical Center following the death of a girl who collapsed in an emergency room restroom shows problems with restroom alarm systems continued two months after the tragedy. The inspection report also shows the hospital failed to maintain accurate records of the girl's vital signs and incorrectly recorded a negative result on a sepsis screening that never occurred.

As a result of the state report, Beebe's "deemed" status was removed, said Emily Knearl, spokeswoman for the Division of Public Health. Beebe was no longer "deemed" to be meeting accreditation requirements of the Joint Commission – a private organization that reviews and accredits hospitals across the country, she said.

This effectively put the hospital's accreditation on hold pending further review.

"Our status was on hold while the investigation was done, and we complied with the terms of the investigation," said Judge Bill Lee, chairman of the Beebe Medical Center Board of Directors. "We're fully accredited with the Joint Commission now. Our standing with the Joint Commission is very, very good."

Lee said he could not recall exactly how long Beebe's accreditation was on hold but it was "however long it took to do the investigation." Kelly Griffin, director of marketing and communications for Beebe, said it was for about a month during 2011.

"Anytime the Joint Commission comes in and says the hospital has short-comings, we address that right away," Lee said.

The Joint Commission inspects the hospital annually and routinely leaves a list of corrections that should be made. Lee said the restroom in which the teenager collapsed is a public restroom that is not required to have an alarm system. Only restrooms requiring alarm systems are checked during internal or commission review; neither Beebe nor the Joint Commission checked the public restrooms in question, he said.

"Sure it concerns us. It concerns us when everything's not perfect, and we strive for that, but perfection is seldom obtained," Lee said.

Unannounced inspection

In July 2011, two months after the girl died, Delaware Department of Health and Human Services conducted an unannounced inspection to examine Beebe Medical Center's restrooms and procedures for unlocking doors if someone is locked inside and can't get out.

The inspection followed an incident in May 2011 when Christina Atkins, 14, collapsed in an emergency room restroom, and Beebe employees could not find a key to open the locked door. A maintenance worker opened the door about 10 minutes later, but by then Christina was unresponsive.

The details of her entrapment came to light in a lawsuit filed in September by Christina's family. She was taken to A.I. duPont Hospital where she died two days later.

The state review of Beebe Medical Center two months after Christina's death determined eight of 12 restrooms checked failed to be maintained to ensure a safe setting for all patients in the hospital.

A Department of Health and Human Services report filed July 21, 2011, gave the following account of one of the restroom checks during a state inspector's visit to Beebe Medical Center July 19, 2011:

The inspector entered a public restroom in the emergency department at 9:03 a.m., locked the door and activated the restroom's emergency call alarm. By 9:50 a.m., 47 minutes after the emergency call alarm had been activated, there had been no response or attempt by hospital staff to answer the emergency call. Another state investigator accompanied by a hospital director responded to the restroom shortly later and took note of the time.

"The director of patient relations and case management confirmed that although the emergency call alarm in the emergency department's public restroom was activated, the alarm failed to notify the emergency department of its activation," the report states.

The same day, investigators discovered emergency call alarms in three other restrooms were not working. A restroom in a cardiovascular area had working alarms, but investigators discovered the area was staffed until 5 p.m. although the restroom was open to the public until 9 p.m., the report states. The restroom, it said, was converted into a staff restroom following the investigators' visit.

During the July 19, 2011 inspection, an investigator also entered the same emergency department restroom where Christina had collapsed. The investigator activated the restroom's alarm, and it took two minutes and 27 seconds for hospital staff to respond. While exiting the bathroom, the investigator observed an emergency key lock box – installed by the hospital directly outside the restroom after Christina's entrapment – had been broken to gain access to the locked door, documents state.

The report also notes the lock on the restroom where Christina became trapped had been replaced in 2010, but the emergency department nurse manager reported a replacement key had never been provided. Neither the emergency department charge nurse nor security had master keys, the report states.

Investigators continued their inspection of hospital restrooms the following day, July 20, 2011, and the alarm system of yet another emergency room restroom was checked. This time, nine minutes and 37 seconds passed before another investigator brought a security manager to the restroom. Unbeknownst to investigators, the report states that alarm was under repair that day; it was working by the end of the day.

Likewise, other questionable alarms were fixed and working, the hospital stated under a corrective plan the hospital is required to submit. The corrective plan said Beebe's director of plant engineering checked all alarms in August 2011; annual alarm checks will be conducted and checks of the nurse call system will be made monthly, hospital officials said in the report. About 95 percent of the staff had been trained in August 2011 on what to do if someone is locked in a restroom.

Beebe Medical Center President and CEO Jeffrey M. Fried signed the Health and Human Services document Sept. 8, 2011, which included hospital comments and a plan of corrections in response to the state's investigation. The report notes required all corrections were completed by Sept. 19, 2011, while some deficiencies were corrected earlier.

Fried did not respond to calls requesting comment but Alex A. Sydnor, vice president of external affairs and president and CEO of Beebe Medical Foundation, said call devices in each hospital bathroom, shower and at each bedside are tested annually. Additionally, he said, staff conducts random weekly inspections of these areas and a committee conducts a semi-annual inspection.

"Some bathrooms in patient rooms have locks on them. For those that do, red emergency key boxes are installed in the unit just as they are for public bathrooms. In addition, the charge nurse on duty on each patient unit has a master key for the bathrooms in patient rooms as a backup," he said.

Key lock boxes were also installed outside emergency department restrooms between May 27, 2011 and Aug. 16, 2011, at Beebe's Emergency Department, Millville Emergency Department and Tunnel Cancer Center, the hospital noted.

Sepsis and vital signs

The state inspection report also found medical personnel failed to properly record Atkins' vital signs while she was at Beebe.

Christina died of respiratory failure resulting from complications from sepsis and possibly toxic shock, her mother, Bonnie Atkins, said in an earlier interview. In the lawsuit filed by Atkins, her husband, Christopher, and Christina's siblings, they charge Beebe failed to properly recognize Christina's life-threatening medical condition.

On May 26, 2011, the day Christina arrived at Beebe Medical Center's emergency room, the state report notes a triage nurse catalogued a sepsis screen for Christina as "negative" even though Christina was never screened for sepsis.

Beebe does not screen patients younger than 18 for sepsis; the nurse said she did not remember why she wrote Christina had a negative sepsis result, the report states.

An emergency department nurse manager "reported that in this case, staff should have left the sepsis screening tool area blank."

Sydnor said adolescents and pediatric patients are treated for sepsis at Beebe if they present symptoms. This is determined by a blood or urine test, he said. In Christina's case, she walked into an emergency department restroom to provide a nurse with a urine sample when she collapsed, locked inside the room.

The sepsis screening tool used by Beebe is based on vital sign readings for adults, which would not be accurate for adolescents or pediatric patients, Sydnor said.

"For this reason, this particular screening questionnaire is not used to assess adolescents and children," Sydnor said.

Beebe Medical Center does not admit adolescent or pediatric patients for the treatment of sepsis; if sepsis is suspected, a patient would be transferred to A.I. duPont Hospital for children or another facility that regularly treats younger patients for sepsis, he said.

The state report also points out Beebe failed to document Christina's vital signs for about 2 ½ hours during her stay in the emergency room. An emergency room nurse "confirmed that [Christina's] medical record documentation failed to provide evidence of blood pressure, pulse and pulse [oxygen saturation level] readings."

However, while the lawsuit states Christina was taken to A.I. duPont Hospital on May 26, 2011, the report notes that a day later,  Beebe's records note: "... Diagnosis Final: Primary: Sepsis ...."

According to Beebe's comments in the report, nurses have since received instruction on properly documenting vital signs and pulse recordings.

Staff instruction, the installation of key boxes and other emergency system upgrades are improvements Beebe made following the state report, Sydnor said.

"Clearly we take it seriously," he said. "That's an expression of our interest in moving quickly when we see an opportunity to improve."