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The Joint Commission - A Non Responding Agency

February 16, 2017

 

 

In this blog post is a complete copy of the letter of complaint that I sent to the Joint Commission this evening.  This is their mission statement:


"Our Mission:  To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value."
 

Below is the letter I sent, I prayed that someone would do something.  I never received more than a standard form letter from them.  When I called, I was informed that "the person" in charge of my case was unavailable.  When I asked who that was, I was told they don't give out their names, not even their first names.
 

To whom it may concern at The Joint Commission,

 

On November 15th, 2016 my mother passed at home.  My father, Kenneth Sandberg, who suffered from Dementia was unable to believe that she had passed.  Subsequently he was sedated by paramedics (during which it took 4 of them to hold him down, he was quite strong, and he ended up with small cuts on his face and arms from glass that broke in the process).  Since he had actually hit an officer with his cane they were going to put him in jail, but since he had cut himself on glass, they took him instead to Broward Health North hospital and BAKER ACTED him for 4 days. 

 

His admission paperwork cite extreme grief and small cuts.  He did not make it out alive.  These are not normally diagnoses that cause death.  Three days later he died from respiratory arrest due to a combination of drug overdose and medicines that contraindicated both with his condition (Dementia as well as a documented past heart attack from many years ago).  

 

I want to mention that in recent months he had a complete physical work up at a hospital in New York and was getting ready to have a hip surgery.  I will be locating these files in the near future.

 

Since this hospital has sovereign immunity in Florida, and since his children are self sufficient and above the age of 24, per Florida statutes there seems to be no accountability and no punishment. I believe this hospital as well as the doctor in charge have committed murder and I am unwilling to accept that their grave use of a license to kill be allowed to carry onto their next victims. I am writing great detail about his case below and have attached his entire medical file as given to me upon my request.  I have had the file reviewed extensively by two medical experts.  Below are the findings:

 

1.  Haloperidol, a medication consistently given to Kenneth Sandberg. This drug is black box listed by the FDA as well as the pharmaceutical companies to not be given to someone with Dementia.  It was administered to him on 11/16, 11/17 and 11/18.  The hospital was informed of his condition on 11/16, but it was also very clear on his admission on the 15th.  Less than 48 hours after the first Haloperidol dose he lost his life.  

 

lets put it this way:  HE ENTERED THE HOSPITAL BECAUSE OF A FEW CUTS AND MENTAL CONFUSION RELATED TO DEMENTIA.  HE DIED WITHIN THREE DAYS.

 

2.  An EKG was done upon his admission.  The EKG showed:  That he had a "inferior farction, age undetermined" This occurred in his late 40's. He was placed on a cardiac floor.

 

3.  Several drugs given are contraindicated for heart patients including Haloperidol, Lorazapam, Depakote, Seroquel and Levoxaflacin.

 

4.  Benedryl was given "for anxiety" this drug is not a drug for anxiety.  Also this drug is contraindicated when using Haldol, especially in an aged patient and is listed as raising the probability for death when given together as well as when given with Lorazapam.  He was on all three.  Several contraindicating drugs were given together:  

 

https://www.drugs.com/drug-interactions/divalproex-sodium,depakote.html - depakote interacts with Lorazepam and seroquel

 

https://www.drugs.com/drug-interactions/quetiapine,seroquel.html , seroquel interacts with Lorasepam

 

https://www.drugs.com/drug-interactions/levofloxacin-index.html?filter=3&generic_only= Levofloxacin interacts with Haldol

 

http://www.rxlist.com/ativan-drug/clinical-pharmacology.htm - Lorazepam half life active when haldol was given

 

https://www.ncbi.nlm.nih.gov/pubmed/15538130 Haldol Half life shows that haldol was active in system when given Lorazepam

 

https://www.drugs.com/drug-interactions/haloperidol,haldol.html Drugs known to interact with Haldol: Seroquil, Depakote, Adivan, Benedryl. Also, disease interaction with Dementia (diagnosis on file)

 

http://www.drugsdb.com/rx/ativan/ativan-drug-interactions/ Drugs known to couteract with Adivan include: Depakote, Benedryl, Lisinopril, seroquil

5.  Why was he given Levofloxacin?  This is a heavy duty antibiotic.  There was no known infection and nothing in his chart which mentions any kind of infection whatsoever.



6.  When they realized they had overdosed him, several red flags come up   A.  He was supposed to have a babysitter by his bedside.  Once certainly signed off as present when he coded, however the notes read:  " "went to check pt color dusky no resp code blue called in pea pt. intubated by hoffberger compressions continue, code blue meds adm pt also received narcan pt. had haldol 5mg im at 0500 and ativan img ivp at 0236"

   B.  This note brings another question:  So they obviously knew they overdosed him, and tried to counteract the overdose with Narcan.  Narcan however does not work for these drugs.  The drug that does is called:  Romazacon.  Narcan is for overdose of Opioids.  

  C.  Narcan is listed on page 19, but is not listed in the medication section.

 

7.  Many nursing notes throughout the chart contradict each other.  Examples:

   A.  11/17 "1609 calm, app poor, tio lethargic, sedation held at this time" medical medicine log says:  1609 1 mg. Lorazepam given.

   B.  11/17:  "18:26 poor appetite, trying to feed him." (so he was lethargic, you gave him more drugs, then tried to feed him? make sense? no

 

8.  On 11/17 Depakote was given simultaneously with Seroquel and Haldol. Lorazepam only 2 hours later

 

9.  He was baker acted, why was no psych eval done?  The hospital saw dementia, I reported he had dementia, no eval?

 

10.  On 11/16 no blood pressures were charted at all and almost zero notes.

 

11.  On 11/15:  Nursing note says:  1340: "improved mental status, verbalizes understanding of DX" she then at 1445 gave 2 mg. of Lorazapam.  WHY?  This made him worse obviously there was no understanding moving forward.

 

12.  11/17: one hour before he codes, two nursing notes in two different areas of the chart.  One says "taking food and fluids well"  the other says "sinus tachycardia" a third notes that his wound was being cleaned.  So all this happened at 0800 simultaneously?

 

13.  With so much chemical restraint for an elderly heart patient why was physical restraint not considered?  

 

14.  He several times was noted as refusing the pads for the heart monitor... so they chose not to monitor his heart on heart affecting drugs that were contraindicating each other?

 

15.  On intake he refused offer of flu and pneumonia vaccines.  he did not believe in these things.  On November 17th when he was drugged out of his mind, they gave it to him anyway.  We all know that if you are already not feeling well that its not a good time to take a vaccine.  He had not eaten, he was heavily sedated, tell me that he changed his mind in his sleep?

 

Below is the timeline and doses of the charted drugs:

November 15th:

time  drug   dose in mg

1445 Lorazapam   2

1626 Lorazapam   2

2037 Lorazapam  0.5

2338 Lorazapam   0.5

 

Drastic increase on November 16th:

time  drug    dose in mg

406  Lorazepam  0.5

639  Benedryl     25

639  Haldol         5

821  Lorazepam  0.5

1159  Aspirin      81

1159  Levofloxin  500

1159  Lisinopril   10

1208  Benedryl   25

1208  Haldol       5

1341 Lorazepam 500

1453  Haldol      5

1523  Benedryl  25

1756  Lorazepam  0.5

2014  Depakote  250

2014  Seroquil  50

2200  Benedryl  25

 

November 17th:  

time  drug  dose in mg

138  Lorazepam  1

951  Levofloxin  500

953  Aspirin   81

953  depakote  250

953  Lisinopril  10

953 Seroquel   50 continuous

954  Lovenox  500

955  Flu Vaccine

957  Pneumonia vaccine

1609  Lorazepam  1

2005  depakote  1

2005  Seroquel  50 continuous

2023  Haldol  5

2201  Lorazepam  1


November 18th, he coded at about 10 am, though they found him looking "dusky" at 0905

time  drug  dose in mg

236  Lorazepam  2

500  Haldol  5

1037  Lovenox  10

1037  Levofloxacin  500

1450  Morphine  2

1621  Lorazepam  2

1626  Morphine  2

1631  Lorazepam  2

 

Will someone PLEASE look into these many incidences of negligence as well as charting discrepancies.  The ability for hospitals in Florida to have sovereign immunity as well as the lack of ability for families to sue for anything outside costs of a funeral create an unequal balance because lawyers are unable to take the case and demand justice as the fees wouldn't even be covered.  These laws are out of balance.  The least someone can do is stop them from killing again and investigate what has happened here.  

 

If there is something else I must do to get this complaint through please advise.  I received this email address from the Florida Agency for Healthcare Administration.


Sincerely,

Melody Page

 

The only response I received was a call from North Broward Hospital, reporting that they had received a call from the Joint Commission and deny all accusations.  There was no investigation, none whatsoever.  When I called the Joint Commission, I learned that they will not give out the name of the "investigator" (per policy), do not return emails nor phone calls.

 

Three additional wrongful death families have documented the same results.  This organization was formed by our government and is supported by federal dollars coming directly from the taxes of US Citizens.  

 

Visit www.floridamedicalrights.org for more information on bringing accountability to Florida's healthcare system today.

 

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