In a typically bureaucratic reaction, the Californian authorities have said they could consider closing down a hospital at the centre of national outrage over a woman who was left to die on the floor of the emergency room.
The Martin Luther King Jr.-Harbor hospital, operated by the Los Angeles County department of Health Services, is located near crime hotspots, and serves poor and minorities in South Los Angeles. Predictably it has been going to seed for sometime.
Complaints of incompetence and mismanagement have poured in and some periodical attempts at overhauling are made.
The death of a woman on the floor of the Emergency Room lobby in the hospital recently once again turned the spotlight on the pathetic conditions there.
After shocking details emerged of the callousness of the hospital staff and a senator pitched in, blasting those responsible, S. Kimberly Belshe, the state's health and human services secretary, said she had thought Hospital had been making a lot of progress toward correcting its problems -- at least until now.
``We are all so taken aback by the recent incidents at MLK-Harbor,'' Belshe said. ``It does call into question the extent to which meaningful progress has in fact been made.''
Belshe said officials are trying to figure out whether more harm would be caused by closing the hospital or keeping it open.
``When do the dangers associated with keeping the hospital open outweigh the dangers of this hospital closing?'' she asked. ``That's a very important balancing act.''
According to a report released Friday by the U.S. Centers for Medicare and Medicaid Services, six staff members -- including a nurse and two nursing assistants -- saw or walked past a dying woman writhing on the floor.
The six are in addition to two others whose roles have already been made public by the media - a contract janitor who cleaned the floor around the woman as she vomited blood and a triage nurse who oversaw the whole episode and pointedly refused requests to intervene. The janitor was counseled orally; the triage nurse was placed on leave and later resigned, the report said.
Ironically triage is a system used by medical or emergency personnel to ration limited medical resources when the number of injured needing care exceeds the resources available to perform care so as to treat those patients in most need of treatment who are able to benefit first.
The report provides the greatest detail to date on the death of Edith Isabel Rodriguez, 43, in the early hours of May 9, which was captured on a security videotape. Besides the nursing staffers and the janitor, three of the employee witnesses were financial services workers.
According to the report, the videotape shows that for about 30 minutes, ``staff members walked past the patient or worked to clean the floor next to her without interacting with her. One staff person was observed sitting behind the financial/registration window and had a view of the patient in the lobby.''
The tape, now in the hands of the Los Angeles County Sheriff's Department, has not been publicly released because the incident remains under investigation. But it was reviewed by the inspectors for the federal report.
At 1:30 a.m., when Rodriguez was ``kicking with her feet'' on the floor, ``two staff members looked at the patient and then walked back through the door to an area within the ER,'' the report said, without specifying who the workers were.
Rodriguez died a short time later of a perforated bowel that probably occurred in her last 24 hours of life, the Los Angeles County coroner ruled. Experts have said her death might have been prevented had she received treatment sooner.
But this episode has drawn national attention, largely because of the videotape and the public release this week of two 911 calls in which Rodriguez's boyfriend and another onlooker unsuccessfully beg sheriff's dispatchers to send help.
In an interview Friday, county health services Director Dr. Bruce Chernof placed the majority of blame on the nightshift triage nurse, who turned away direct requests for help from police officers who had brought in the woman from benches in front of the hospital, where she was crying for help. That nurse, Linda Ruttlen, resigned days later and has since been referred to the state nursing board for investigation.
The federal government cited the hospital for violating the Emergency Medical Treatment and Active Labor Act, which requires hospitals to screen and stabilize all patients seeking emergency care.
In a written response, hospital officials said they had made changes, such as adding training for emergency room staff, improving methods for logging patients seeking treatment and posting additional signs advising patients of their right to a medical exam.
From now on, county health officials said, a supervising nurse will check the emergency room waiting area at least once every eight-hour shift to ensure that no patient is left unattended.
King-Harbor must still respond to a separate federal report, not yet released, that found emergency room patients in immediate jeopardy of harm or death. That survey was based, in part, on the experience earlier this year of a brain tumor patient who waited fruitlessly in an emergency room bed for four days before giving up and seeking emergency surgery at another hospital.
Responding to the uproar caused by Rodriguez's death, the chairman of the U.S. Senate Finance Committee on Friday asked federal regulators to explain how they plan to protect patients at King-Harbor in light of ``horrific'' and ``appalling'' lapses in patient care.
In a letter to the Medicare agency, Senator Max Baucus, said he was concerned about the quality of care being delivered at the hospital.
In the last 3 1/2 years, King-Harbor has made significant changes, including closing its once-busy trauma center, disciplining hundreds of workers, slashing services and reducing the number of inpatient beds from more than 200 to 48.
Now the entire hospital is in danger of being closed down permanently.