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Report : Hospital patient not monitored before death

BEND — The St. Charles Medical Center in Bend has been accused of violating procedures following the death of a patient in December who received the wrong medication from a nurse at the facility.

A U.S. Centers for Medicare & Medicaid Services report detailed three violations the hospital committed during the treatment of 65-year-old Loretta Macpherson. The report says the Sisters resident was given the wrong medication, and the hospital violated patient rights and failed to supervise Macpherson with a cardiac monitor after starting an IV medication.

Macpherson went to the hospital's emergency room Dec. 1 with symptoms of anxiety and concern about medications she was given following brain surgery in Seattle. A pharmacy technician gave Macpherson rocuronium, a paralyzing agent, and wrongly labeled the IV bag as containing fosphenytoin, the anti-seizure medication Macpherson's physician had ordered.

The drug caused Macpherson to stop breathing and she suffered irreversible brain damage. She was taken off life support Dec. 3 and died shortly after.

The federal report shows the nurse had started oxygen monitoring but discontinued it and never started the heart monitoring.

"The CNO (chief nursing officer) acknowledged that if the patient had been on cardiac monitoring as ordered, an audible alarm would have sounded and alerted staff at the nurse's station when the patient's cardiac status declined," the report states.

Dr. Michael Boileau, St. Charles' chief clinical officer, told The Bend Bulletin in December that monitoring Macpherson's vitals hadn't been necessary.

"There wasn't any indication to do so," he said at the time. "Her management and the degree of surveillance and observation that she was given was appropriate for the medicine that the staff believed she was receiving."

Macpherson's two sons are working with attorneys in Bend to determine whether they will seek damages for pain and suffering as well as punitive damages in the case.

An attorney for the health system said St. Charles responded to the federal report with the required plan of corrective actions in April. The health facility has not publicly released the plan.