An investigation into what allowed a second patient in two years to simply walk away from a San Diego health care facility revealed broken alarm systems that were known to be inoperable but went without repair.
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 in May 2013
The lapse in hospital security led to a tragic search which ended when 57-year-old Thomas Vera’s body was found five days later less than a mile from the hospital entrance in Palm Canyon.
Vera’s family blamed the hospital for allowing the man suffering from severe head and neck injuries 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.
UCSD Medical Center has since added a policy where patients like Vera are given orange wrist bands as a visual clue they shouldn’t be walking around unattended.
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. In response, UC San Diego Health System submitted plans of correction to the California Department of Public Health which were accepted and implemented. In the instance of the panic buttons, the buttons have undergone a software upgrade and are tested monthly for functionality. We remain vigilant in training employees to communicate quickly and effectively with our hospital security team so that responses to patient needs are timely, with safety as the first priority.”
Fifteen months after the incident, CHHS says no fine or penalty has been issued as a result of the mishap.
“The state said ‘Oh well, you made mistakes.’ UCSD fills in a plan of corrections saying ‘OK, we’ll do our best to make sure this doesn’t happen again,’ and to a family, that’s not going to be enough” said Bryant.
An NBC 7 records search also found the hospital paid the Vera family $85,000 in a settlement.
Vera was the second walkaway from UC San Diego Medical Center in the past two years, according to the California Department of Public Health.