A climate of "fear and retribution" existed within the now-shuttered liver transplant program at St. Vincent Medical Center, keeping staff members from speaking up about a major breach in national transplantation standards and prompting them to falsify documents as part of a coverup, according to a new federal report.
The U.S. Centers for Medicare and Medicaid Services, in its stinging 99-page report, found serious deficiencies at St. Vincent and said the hospital was out of compliance with eight conditions that must be met by hospitals receiving federal money. If the problems persist, the Los Angeles hospital could ultimately lose its federal funding.
The Times obtained the report, based on an inspection in October, under the federal Freedom of Information Act.
The federal inspection was prompted by the hospital's admission in September that its doctors had improperly arranged for a transplant to a Saudi national using an organ intended for a higher-priority patient on St. Vincent's medical list. The unauthorized action bypassed dozens of people on a regional waiting list whose conditions were considered more dire.
In its response, included with the report, the hospital said it had established a new transplant committee that reports directly to the hospital's governing board, provided additional training to transplant team members, developed new ethics materials and created a hotline for employees concerned about medical quality.
Although the improper transplant occurred in September 2003, it was not discovered until two years later, when the hospital was responding to questions raised during a routine audit.
The hospital has acknowledged that a number of staff members knew about the ethical breach but participated in the coverup.
"Several transplant staff members described a working environment that did not foster openness but 'fear and retribution,' especially when staff voiced certain complaints or grievances or even when making recommendations," the report said. "One staff member stated that the transplant director at the time had a 'my way or the highway' attitude that prevented staff from raising any concern."
In fact, when one employee tried to alert a manager to the misallocation of the liver a day after it happened, the report said, she raised her hands, said, "Don't tell me ... I don't want to know, I don't want to know" and continued walking.
Inspectors also found several instances in which transplant staff members said they were asked to falsify documents, as well as examples in which the top liver transplant surgeon, Richard R. Lopez Jr., misled the patient for whom the donated liver was originally intended, Saad Al-Harthi.
As recently as this year, when the hospital was responding to the audit, a transplant coordinator said Lopez told her that "we can make medical records disappear." The report quoted the coordinator as saying that the surgeon told her that because both patients were foreign nationals, "it would be easy to change their names." The report identifies Lopez by title, not by name.
After the September 2003 transplant, the hospital removed Al-Harthi from the waiting list but led him to believe that he was still a candidate for an organ. He died in 2004, his son said.
Al-Harthi and the patient who received the liver, Abdullah Al-Bugami, were Saudi nationals receiving care at St. Vincent paid for by the Royal Embassy of Saudi Arabia.
In September, when the problems became public, St. Vincent terminated its contracts with Lopez and another surgeon, Hector Ramos, and suspended the liver transplant program. St. Vincent subsequently closed the program, forcing the 75 patients on its waiting list to seek care at other centers.
In separate interviews with inspectors in October, the two surgeons blamed each other for failing to notify authorities that someone other than Al-Harthi, the intended recipient, had received the donated liver two years earlier, the report said.
Ramos told inspectors that Al-Bugami was hospitalized and "seriously ill," but inspectors said he did not take steps to move him up the transplant waiting list if that were the case, the report said.
Lopez's lawyer, Daniel Willick, said that although neither he nor his client had seen the report, Lopez "didn't do anything wrong and he always acted to save the lives of his patients. He absolutely denies that he gave any orders to cover anything up or to submit false information."
"It is absolutely at odds with what my investigation shows," Willick said.
Ramos' lawyer, Evelina Serafini, said the suggestion that her client was cavalier about transplantation rules "is, to say the least, inaccurate."
"I don't know how they reached that conclusion," she said, adding that Ramos told employees to report accurate information to the national organ network about the patient who received the transplant.
The federal report found problems beyond the September 2003 transplant.
Based on hospital records, there was no proof that some patients received a physical examination, appropriate screening tests or psychosocial exams before being added to the transplant list. In several cases, there were no records showing that transplant patients were even reviewed by a selection committee before being accepted for the list.
And in one case, the hospital removed a patient from the waiting list saying the patient had been listed in error. In fact, the patient had died at another hospital. Government inspectors said such inaccuracies can undermine the accuracy of national reports comparing transplant centers.
The hospital said it had taken steps to improve its medical documentation.