The deaths of four patients in January and February who had been treated at a Kaiser Permanente hospital east of San Francisco prompted state and federal investigators to conduct a surprise visit to the facility on March 26.
The ongoing inspection concerns Kaiser Richmond (Calif.) Medical Center, where patients died after being transferred out of a standby emergency room. Richmond is a working-class suburb north of Oakland.
Kaiser medical staff have said the patients' treatment was delayed because they could not locate available critical-care beds in which to place the patients (See related story, p. 82).
The state Department of Health Services sent 12 evaluators to conduct a validation survey at Kaiser Richmond and Kaiser Oakland Medical Center on behalf of HCFA, said Gil Martinez, district manager with the California Department of Health Services in Berkeley.
Responding to complaints from patients' families and the California Nurses Association, the state already conducted a preliminary survey. Its findings gave cause to do a more thorough investigation.
As the local deeming authority for Medicare and Medicaid, the department's licensing certification division then asked HCFA to authorize and pay for a full validation survey.
Survey team members left the hospitals last week and are expected to prepare their report for HCFA within two weeks. The agency will respond and possibly levy sanctions after that.
Katherine Saux, Kaiser's local communications manager, said, "They are casting a rather wide net, to verify whether the numerous allegations being brought against Kaiser Permanente have any foundation, and if so, what steps will Kaiser Permanente take to rectify them."
Rose Ann DeMoro, executive director of the CNA, said, "We're obviously pleased to see the federal government is acting responsibly." She said the CNA also filed a claim with the state Department of Corporations, which regulates HMOs, about closing down emergency services.
The deaths occurred during or after transport of emergency patients from Kaiser Richmond to other nearby hospitals.
The 50-bed Richmond hospital has an average patient census of fewer than 10 a day, Saux said. Since its construction in 1942 as a shipyard hospital, it has always had a standby emergency room, she said.
That means it can handle routine emergencies but not life-threatening events such as traumas or heart attacks. The hospital lacks a critical-care unit or backup technology to handle those events, she said.
But that's not the whole story.
Martinez, of the Department of Health Services, said the Richmond facility contains an ICU that Kaiser doesn't staff. Kaiser built a new facility in Richmond in 1995 to replace its older building, but "the hospital was never fully opened," Martinez said. "The equipment is there, the room is there, but the Kaiser corporate people felt there was not sufficient membership to justify opening those units."
Patients with traumatic injuries or heart attacks are normally transferred to a nearby full-service emergency room, Saux said.
In the instances at issue, patients either drove themselves or were taken by relatives to the Kaiser Richmond emergency room. One woman, Willa Hives, 39, drove herself there with chest pains on Feb. 15. She died in the ambulance en route to another hospital.
Of the others, Martinez said, "some had prolonged waits, some were taken off to other facilities. Four patients died out of the five. (One nonfatal case is also being investigated.) These are only allegations at this point."
In none of the cases did ambulances deliver emergency patients to the Richmond hospital.
"It's terribly unfortunate that we've had these incidents so close together," Saux said. Kaiser is fully cooperating with the state DHS, she said, and is mounting its own internal investigation to learn "what could we have done differently? Did the systems work? Could other decisions have been made?"
Kaiser has not received any notice of inspection from the Joint Commission on Accreditation of Healthcare Organizations, Saux said.
The series of events has prompted some reflection in the East Bay region as to the adequacy of emergency services and critical-care capacity in a hospital marketplace that has mercilessly squeezed excess beds and staff out of the delivery system.
Kaiser, in fact, wants to shut down its 220-bed Oakland hospital. It plans to contract with three other hospitals to accept its HMO enrollees. The CNA opposes the closure.
The state investigators visited Kaiser Oakland Medical Center because the Richmond and Oakland facilities operate under the same license. The California Nurses Association has filed complaints about nurse staffing levels at the Oakland hospital, and that is also being checked out by the state.