A 70-year-old man who collapsed from a heart attack on the south lawn of a Baltimore hospital and died a half-hour later was twice refused treatment by medical personnel who thought he was drunk, an investigation by state regulators has found.

Nurses refused to help Edward G. Davis despite frantic pleas from Harbor Hospital Center's security guard, who at one point "grabbed" an emergency room doctor to get help, a report says.

Federal health officials, who reviewed the state report, ordered the hospital to rewrite its rules on how to treat patients to avoid a repeat of the July 27 incident, which one official called "a very serious matter."

The hospital was found to have violated a federal law that requires medical personnel to see patients who arrive at the hospital. Harbor officials confirmed that the hospital was sanctioned but was spared the severest penalty -- loss of its Medicaid funding.

The hospital's president, L. Barney Johnson, disputed key parts of the state report and said in an interview that three doctors and a nurse gave Davis prompt assistance. "The gentleman was treated," Johnson said.

Davis was pronounced dead at 7: 32 p.m., a half-hour after he had collapsed outside the South Hanover Street hospital. He had rushed there with his daughter and ailing grandson, an 8-week-old premature baby who showed signs of pneumonia.

"My dad had another 10 years left in him," said Leonard J. Davis, 45, the victim's son, who saw his dead father lying on a gurney in the emergency room. "He was dead. I'll never forget what he looked like. There was still a tube in his mouth."

Relatives said Davis had a physical in April and an electrocardiogram in May, neither of which revealed any problems.

Carol Benner, director of license certification for the state Department of Health and Human Services, said that about one Maryland hospital a year is cited for turning away patients at the emergency room door.

But Benner said, in most cases "the patient is able to leave the hospital and get care somewhere else." She said it is "very unusual" to have a fatality. "The hospital has instituted a new policy on how to care for people who get into trouble outside," she said.

Claudette Campbell, an official with the Philadelphia-based federal Health Care Finance Administration, refused to say what sanctions have been levied because Harbor officials have yet to respond to the violation notice, which was sent on Tuesday.

Policy changes

Johnson, Harbor's president, released a statement listing seven policy changes that he said answer the concerns of the regulators. They include training classes, a rule mandating treatment of anyone on the hospital grounds, and classes to remind staff members of federal regulations.

"This isolated incident is being carefully reviewed by our staff and we are taking it very seriously," the statement says. "We immediately redirected our processes as well as refined and clarified our procedures."

Harbor Hospital Center security officials reached by phone yesterday refused to comment or name the guard involved in the incident. The paramedics for a private ambulance company, Transcare of Glen Burnie, who treated Davis on the lawn, have left the company and could not be reached for comment.

Johnson refused to identify the doctors, nurses or security guard involved. State officials also declined to name them, and deleted references to names from the report, which they released at the request of The Sun.

The report does not say why the hospital failed to treat Davis, but cites several possibilities, from outright refusal by emergency room workers to render assistance to an argument about who was supposed to help.

The elder Davis accompanied his daughter, Veronica Moyer, 37, and her son, Michael Moyer, to Harbor Hospital Center about 7 p.m. Davis became ill and decided to wait outside.

At 7: 02 p.m., a passer-by saw Davis collapse on the south lawn and called a hospital security guard. "The security officer's log indicated that he 'went to investigate a man laying in the grass," the report says. "911 notified intoxicated male. Dr. notified. Refused."

The paramedics drove by, stopped and determined the man was suffering a heart attack. They asked the guard to get a doctor.

"The security officer's log indicated that he told the ED [Emergency Department] that the patient was in full arrest and the Emergency Department again refused assistance," the report says.

"The nursing supervisor's incident report indicated that she was notified by security 'about a drunk on the S. lot,' unconscious, and later he was a full arrest," the report says. "Her incident report indicates that there was an argument about who was to respond.

"A security officer went to the ED and 'grabbed Dr. [name deleted], told him what he had and he came out. The security officer indicated that the charge nurses in the ED had apparently not told the doctors. The physician returned to the parking lot and assisted with emergency care."

But by that time, the report says, a city ambulance and fire engine had arrived. Davis was carried into the emergency room, where he was pronounced dead.

'Over in a minute'

Moyer said she was upstairs in the hospital's pediatric unit when her father died.

"I heard a man in the hallway asking a nurse whether she had heard 'about the old man that had a heart attack outside,' " Moyer said. "I ran into the hall and asked for a description of the man. Right then, I knew it was my father and ran down to the emergency room. A security guard got a social worker or someone to take me aside.

"I kept asking if my dad was OK," Moyer recalled. "I asked everyone I saw. No one would answer me. Finally, three or four doctors came in and started asking me questions about my father's health."

Moyer said doctors questioned her at length about whether her father ever drank, smoked or took medications. Eventually she refused to answer any more questions until they told her what had happened to her father.

"I thought they needed the information to treat him," Moyer said. "The whole time, I'm asking whether my dad is OK. Finally a doctor says, 'Well, I'm sorry, but your father has passed.' That was all that was said. 'It was over in a minute.' "

Davis had raised his three children alone on the salary of a furniture deliveryman for Montgomery Ward, after his wife left the family. He had lived with Moyer for the past 12 years in Glen Burnie.

Moyer said she heard that medical personnel did not rush to her father's aid because "they thought he was just a drunk passed out. That just makes me so mad. He never drank a day in his life."

Pub Date: 8/15/98