Family had been kept in the dark about mother's final moments at Kindred Hospital Sugar Land
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Manuela Chapa, on her 85th birthday in 2012.
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The package came in January: An anonymous letter and a stack of
government records, stuffed in a yellow envelope with no return address
and mailed to her late mother's home in Damon.
Cris Chapa ripped it open and began to cry.
She thought of the day, March 12, 2015, when medical staff at Kindred
Hospital Sugar Land sat her down in a waiting room. They'd said there
was nothing anyone could have done. Led her to believe her 87-year-old
mother's death had been the inevitable result of her bout with
pneumonia.
The stranger's letter told a different story:
Her mother hadn't died peacefully, it said. Instead, a doctor had
attempted a procedure without Chapa's knowledge or legal consent, and it
had gone badly. Blood poured from a tube in her mother's neck. Soaked
her hospital gown. Caused her heart to stop.
Why hadn't anyone told her what happened? Why didn't anyone tell her
three months later, when the state sent someone to investigate? Why
didn't anyone tell her a few weeks after that, when the federal
government cited the hospital for violating her mother's rights?
For nearly two years, Chapa and her family had been kept in the dark. Until now.
She didn't know it then, but the stranger who'd written the
letter had mailed duplicates to two of her siblings. Chapa's hands shook
as she studied the documents, looking for clues to who'd sent them, but
found only an email address.
That night, she logged onto her computer and typed a message: "Can you call me?"
***
Linda Patton read the email twice, unsure how to respond. She'd been
hesitant to contact Chapa in the first place, even anonymously. She'd
already lost so much.
This wasn't the life she'd hoped for when she accepted a job as a
nurse practitioner at Kindred Hospital Sugar Land in September 2014. She
knew it had been a risk leaving Houston Methodist Hospital for a
less-prestigious facility, but Kindred had offered her a more senior
position and an opportunity to mentor young nurses, which was her
passion.
Patton noticed problems right away, she said. On daily rounds, she'd
quiz nursing staff on what medications patients were taking. What side
effects they should be looking for. Basic stuff. Routinely, though,
nurses didn't know the answers, and some seemed agitated by her attempts
to educate them.
"That just kind of shocked me," Patton said.
She hadn't realized her new hospital had a history of mistakes. In
the three years leading up to her first day at Kindred, the federal
Centers for Medicare and Medicaid Services had cited the facility for
10 separate violations of state rules governing patient care.
Among the citations, obtained by the Houston Chronicle through a
public records request: Kindred nurses weren't adequately trained or
supervised. Patients had been unnecessarily restrained. Others had
suffered infections after staff mishandled contaminated materials or
failed to properly wash hands. Administrative safeguards weren't in
place to prevent future mistakes.
In 2012, according to one citation, a patient in Kindred's intensive care unit became
disconnected from a breathing machine
and was left to die, even as an alarm sounded, alerting staff of the
problem. One staffer who heard the beeping said she didn't know what it
meant.
J. David Cross, the chief executive officer of Kindred's Houston-area
district, defended the hospital's quality of care, noting that the
facility
exceeds national benchmarks for complication rates.
"We take seriously any issues brought to our attention by regulatory
authorities, and work with them to address any concerns," Cross wrote in
an email to the Chronicle. "We share the same goal — to provide quality
care to our patients."
Patton was troubled by the problems she saw but felt she'd begun to
make progress. Some nurses had become receptive to her on-the-job
training, she said, and hospital leadership initially seemed to
appreciate her efforts to instill a more professional culture.
She'd been there seven months when Cris Chapa brought her mother, Manuela, to the hospital with pneumonia.
Patton checked on her daily and saw her condition grow worse over the
course of two weeks. The illness put a strain on her frail heart. Her
lungs began to fail. So did her kidneys.
Before leaving for the day on March 12, 2015, Patton checked in on
Chapa once more. It seemed clear to her that she might not recover.
Patton assumed doctors would soon be meeting with the woman's family to discuss their options.
***
The next morning, as she arrived at work, a respiratory therapist
grabbed Patton by the arm and pulled her aside: "Oh my God, Linda," she
said. "It was terrible."
The therapist had been in the room the afternoon before, when Dr.
Yassir Sonbol, an interventional cardiologist, tried to insert a
catheter in a major vein in Chapa's neck, in the hopes of starting
dialysis.
The treatment might have eased the burden on Chapa's kidneys —
but it also came with risks.
On his first attempt at inserting the line, according to medical
records and witnesses, Sonbol couldn't get the catheter to stay in the
vein. So he tried again on the right side, but this time, the wire got
stuck, and Sonbol struggled to get it out. (
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She believed her mom died peacefully. Two years later, a nurse wrote to say what really happened
