Investigative findings released by the California Department of Public Health do not hold Paradise Valley Hospital responsible for failing to detain a patient who died after leaving the hospital’s intensive care unit on Aug. 11, 2022.
A CDPH “statement of deficiencies” report obtained last week instead finds that the National City medical facility should have more thoroughly documented the condition and circumstances of Alberto Herrera, 32, who fell unconscious in front of a nearby taco shop after walking out against the advice of his caregivers.
Joanna Hurtado, Herrera’s ex-fiancee and the mother of his two children, filed a state complaint after his death, telling state regulators that given the evidence contained in his medical records, a mental health hold or other means should have been used to keep him from leaving Paradise Valley.
“Because of them, my daughters and I have cried for 323 days because we miss Albert,” Hurtado said Friday.
First responders found him collapsed in front of a nearby taco shop about an hour after he left, taking him back to Paradise Valley’s emergency department where he died not long after arrival.
Herrera’s case was documented as an elopement, but medical and security personnel interviewed by a state investigator indicated they thought his departure should have been categorized as leaving against medical advice as employees advised him to stay.
There are indications that the investigation did explore whether Herrera should have been kept at Paradise Valley on a “5150” hold. Such holds allow holding a person against their will for up to 72 hours if their behavior is believed to put themselves or others in danger or if they are considered to be gravely disabled and unable to care for themselves.
Findings indicate that a security officer on duty in Paradise Valley’s emergency department on Aug. 11 said he did not believe that Herrera met the criteria for a “5150” hold “because he wasn’t aggressive, and he seemed clear, he didn’t have slurred speech or hostility, he was a nice guy and, if I had met him on the street, I would probably be friends with him.”
The officer told an investigator that had he believed Herrera was trying to elope, rather than leave against medical device, he would have called a “code green,” which would have caused personnel to close all of the building’s exits to keep him inside. Instead, security guards “escorted the patient out of the hospital, and he walked out without their help.”
But Herrera’s medical records, which were obtained by Hurtado as the legal guardian of his next of kin, provide additional insight into his behavior leading up to his departure.
Nursing notes and other documents show that Paradise Valley admitted Herrera on Aug. 10, 2022, suffering from acute pancreatitis, kidney failure and the symptoms of suspected alcohol withdrawal. Overnight, nursing notes show that he became increasingly agitated, giving confused answers to nurses’ questions, pulling out intravenous medication lines and ripping soft restraints on his arms that were put in place to keep him in bed.
A nurse documented that Herrera’s affect was not in a steady state, with his agitation and confusion waxing and waning during his stay. Still, shortly before his departure, his nurse wrote that he attempted to leave the hospital covered only in “a bed sheet covered in drops of blood.” Hospital personnel, notes state, found Herrera donated clothes to properly cover himself while simultaneously pleading with him to remain in his room and not leave the hospital.
Hurtado said she cannot understand why caregivers did not heed her request to have Herrera assessed for a mental health hold.
“Their deficiency is that they didn’t chart correctly, and that they need to chart better,” she said. “They get a slap on the wrist; they get away with it as if his life did not matter.”
In its formal “plan of correction,” which is included alongside the state’s findings, Paradise Valley indicates that it re-educated intensive care workers on the differences between leaving against medical advice and elopement. Patients found to be not in their rooms, the plan states, must be searched for and found if they do not return within two hours.
Paradise Valley also states that the rules for placing patients on involuntary 5150 holds were also reviewed with staff. The hospital committed to monitoring the documentation of cases where patients leave against medical advice “for 60 days or until fully compliant” and the hospital said in a statement Friday that it “immediately addressed the findings on the document,” and “resolved each finding to the satisfaction of the CDPH.”
Paradise Valley was among facilities in San Diego County given an A hospital safety grade in the latest report from The Leapfrog Group, a nonprofit that assesses hospitals nationwide.
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