Health care regulators sanctioned LewisGale Medical Center last year for keeping the body of a deceased patient in an unrefrigerated morgue.
But that wasn’t the only problem with the care of the patient, an elderly man who had been hospitalized before being rushed to the Salem hospital emergency room. According to a government report, hours before he died, a nurse left him groaning in pain to go to lunch.
“Facility staff failed to ensure that a patient (Patient #3) received caring, respectful, compassionate and dignified care,” regulators said in the September 2022 report.
Struck by findings that it was not complying with federal health care standards, a necessity for receiving payment from government health insurance programs, LewisGale strengthened its practices to the satisfaction of regulators, ending the case without any sanction.
People also read…
Neither the Centers for Medicare and Medicaid Services nor the hospital have announced the paper, written 13 months ago by Virginia Department of Health investigators working on behalf of the federal agency. The Roanoke Times obtained the report last month while preparing an unrelated story about a future hospital project in Bonsack.
The hospital declined to make an official available for an interview. It released a statement saying: “We strive to always provide high-quality, compassionate care and treat people with dignity and respect. In this case, last year we did not meet our standards.
LewisGale continued: “An action plan has been implemented along with monitoring to ensure continued compliance. The Virginia Department of Health reviewed our action plan and re-investigated the hospital, finding the hospital to be largely compliant.
A Roanoke Times investigation identified the individual as Robert Russell King, 64, who was admitted to the hospital suffering from liver cancer and a history of stroke and died within the day. Problems with organizing the cremation delayed the transfer of his body to a funeral home.
His corpse remained in the hospital morgue from July 2, 2022 to September 1, 2022 and entered an accelerated state of decomposition, according to the report. The problem was traced to a malfunction in the body cooler, which went undetected by staff until it failed completely and allowed the temperature to rise more than 15 degrees above the recommended levels, according to the report.
In 2022, the Medicare and Medicaid programs paid $17 billion to LewisGale Medical Center’s parent company, HCA Healthcare Inc. of Tennessee, according to an HCA financial report. There is no indication that any money was withheld due to the incident. LewisGale Hospital is a major regional healthcare provider that opened in 1909 and is licensed for 500 beds.
In the northeast Roanoke trailer park where King lived, residents remembered a man they called “Rob” as a flower lover who lived with a dachshund-beagle mix dog named Digger. King had worked for years as an upholsterer, according to Brenda Almond of Salem, his sister.
As King’s health deteriorated, he had to abandon his dog, who was placed for adoption at the Regional Animal Care and Protection Center and adopted shortly after. During his final months, King attended a walk-in baptism at a Roanoke church. A neighbor shared a photo of King in the float, his red wheelchair on its side, receiving blessings from a minister holding a microphone.
“This is probably one of the first times I’ve seen him smile,” said trailer park resident Austin Mendenhall.
By this time, the frail king had begun living in the home of a longtime friend in Salem.
On July 1, he collapsed and was taken by ambulance to LewisGale Medical Center, where he was admitted, according to Almond and government records. Doctors had prescribed oxycodone for pain, to be administered as needed every four hours, according to the Medicare report, which also detailed his stay as “Patient #3.”
At 9:09 a.m. the morning after admission, he was given painkillers by a nurse and rested for a while, but then complained of pain and groaned. The nurse told him that now was not the time to give him more painkillers, but that she could bring more when he returned from lunch or, if he couldn’t wait, that she could contact doctor.
The nurse went out for lunch at 11:51.
In the middle of the nurse’s break, at 12:09 p.m., King hit the three-hour mark when he “could have been medicated again,” according to the report. The nurses had the discretion to administer pain relief up to an hour earlier or an hour later.
Although she knew he was in pain before the nurse left for lunch, the nurse, who returned from lunch at 12:27 p.m., did not check on King until 12:56 p.m.
“There was no evidence in the clinical record that any other nurse administered medications during this time, nor was the physician contacted,” the report states.
Asked later by investigators how King was treated, the nurse responded, “I should have put the patient’s needs first.” It was inappropriate.
The hospital placed King’s body in the morgue “until it was determined who would be responsible for the disposition of the remains,” the report said.
King’s friend and sister informed Salem Sheriff’s Office April Staton that they could not afford to pay final arrangements. In such a case, state law allows the sheriff to petition the court for assistance, but the sheriff was ultimately unsuccessful in doing so. King’s family, Simpson Funeral Home and Crematory in Roanoke, the Roanoke office of the Virginia Department of Human Services and hospital staff worked for several weeks to arrange for King’s transfer to the funeral home on September 1 for cremation, according to sheriff’s records. .
In an effort to identify “Patient No. 3,” the Roanoke Times obtained a copy of the records asking if the sheriff helped make arrangements for anyone who died in LewisGale on July 2, 2022.
No part of the Medicare investigation report names King.
While the parties arranged the cremation, his body deteriorated in the morgue. About 10 days before the body was transferred, a hospital staff member discovered that the body cooler that records show contained King’s body was not cooling, according to the report. Staff applied ice and brought in a portable air conditioning unit, while repair personnel began working to fix the problem, according to the report.
But an immediate and comprehensive solution has proven elusive.
More than three weeks after King’s body was removed, Medicare investigators showed up unannounced to investigate a complaint involving King and visit the morgue. Although no bodies were present, one thing that stood out was that the meter on the body cooler read 55 degrees. A stored body is supposed to be kept between 36 and 39 degrees, the hospital later admitted to investigators.
Staff members reported that there had been a body in the morgue for an extended period of time and “there was an odor,” the report states. Probing the extent of the outage, investigators requested a history of temperature monitoring for the morgue, a temperature monitoring procedure or clarification on who was in charge of the morgue area. Staff couldn’t provide any of that, the report said.
“Due to the lack of temperature monitoring, facility personnel failed to recognize when the cooling system was failing until it became completely non-operational and the temperature exceeded considerably beyond the recommended range. This resulted in accelerated decomposition of the remains of one patient (Patient #3),” the report states.
Inspectors also noted dirt on the floor, a dried substance on a metal table and soiled items including instruments and hospital gowns, according to their report.
Hospital officials responded by implementing, among other measures, a temperature monitoring practice for the morgue’s body storage cooler and a cleaning program.
The Medicare organization came back a few months later for a follow-up visit, found conditions to be good, and closed the case. “No sanctions have been issued against the establishment,” said a Medicare spokesperson who requested anonymity.
King’s ashes rest in a container next to his mother’s on the fireplace mantle of Almond’s home. There was no funeral or obituary.
Jeff Sturgeon (540) 981-3251