The deadly troubles at Kindred Hospital began four years ago with a routine decision by a nurse to help patient Priscilla Richey, 76, feel more comfortable.
The Anoka woman was injected with the wrong pain medication. It quickly killed her and led to the first of 11 investigations that revealed a pattern of problems in patient care and hospital management.
The nurse who took responsibility for Richey's death in March 1998 admitted looking only "briefly at the label on the medication box," an investigative report said.
Kindred, a small long-term-care hospital in Golden Valley, promised the government that it would correct and prevent its problems -- a pledge it repeated in the years ahead.
Yet it would take three more patient deaths and 53 violations before federal investigators decided they had seen enough. Regulators dropped the hospital from the Medicare and Medical Assistance programs on April 5, apparently the first time that has happened in Minnesota.
Now, as the hospital faces imminent shutdown, former patients and their families say they are frustrated and angry over the problems they witnessed and the government's response to them.
Among other problems, Kindred's mishaps with medication continued. Since 1998, government regulators found medication errors with 22 other patients, though none died, the investigative reports say.
The investigators also described delayed tests, incomplete medical records, failure to follow doctors' orders. In addition, there were cases of nurses not wearing gloves or not washing their hands when required.
Kindred's administrator, Bonnie Blake, said the hospital hasn't had major problems since the three care-related patient deaths in 2000. Every hospital has some incidents, she added, but Kindred's procedures and policies have improved under new management, making the Medicare cutoff unwarranted.
An inspection by the Minnesota Health Department this year found a medication mistake similar to the one that killed Richey in 1998. Regulators recently reported that a Kindred patient went into respiratory arrest in January after getting the wrong dose of an intravenous drug. The nurse didn't carefully read the medication label, which listed a different patient's name. The patient survived.
Blake said the medication errors of March 1998 and January 2002, which involved different nurses, "are not in any way related." She said additional safeguards are in place. The nurses' names have not been been made public.
Kindred, which is licensed for 92 beds and recently has filled about a quarter of them, will lose funding for its current 16 Medicare and Medical Assistance patients by the first week of May. It also can't take on new patients from those programs. The loss of the government eligibility is likely to cause the hospital to close, according to the Health Department.
No fines for hospitals
In Minnesota, most hospitals can't be fined for violating regulations -- even when a patient dies as a result.
Instead, regulators try to correct shortcomings.
Kindred retained its accreditation from a private organization and kept admitting patients after Richey's death and the resulting state-federal investigation.
State Health Department officials, who conduct inspections on behalf of the Medicare and Medical Assistance programs, checked on Kindred later in 1998 and spotted no new problems. The case was closed.
Once that happens, government inspectors don't go back unless they receive another complaint.