Chapter 4 - The Second Chart
The NCIS investigation began within twenty-four hours.
The senior agent in charge was a woman named Special Agent Alicia Moreno. She was forty-one years old and she had spent eighteen years in naval criminal investigations and she had seen her share of medical record fraud. She was careful and she was methodical and she did not have a great deal of patience for people who lied to her.
She interviewed Grace Holloway for two hours on the second day.
She interviewed Commander Reed for three hours on the second day.
She interviewed the charge nurse, the two night nurses, the two day nurses, the two residents who had rotated through the pediatric ward during the patient's stay, Lieutenant Commander Howard, and Commander Whitfield.
Then she sat in a small conference room with the two charts in front of her and she read them side by side.
The differences were not subtle.
The bedside chart had a nursing note at 03:15 on the night of the incident. It said:
"0315: Patient awakened by coughing. T 103.4. HR 132. RR 32. O2 sat 89% on 2L NC. Notified on-call pediatrician (LCDR Howard). Ordered: acetaminophen 15mg/kg PO x1. Cooling blanket initiated. O2 increased to 4L NC. Family at bedside. Father informed of plan of care and expressed understanding. Will recheck vitals q15 min."
The official chart had a nursing note at 03:15 on the night of the incident. It said:
"0315: Patient resting. T 98.9. HR 108. RR 24. O2 sat 96% on 2L NC. No acute events. Father at bedside. Plan: continue current care."
The bedside chart had a nursing note at 04:40 that said:
"0440: T 100.1. HR 118. RR 28. O2 sat 92% on 4L NC. Cooling blanket discontinued. Father informed of improvement. Will continue to monitor."
The official chart had no 04:40 note.
The bedside chart had a nursing note at 06:15 that said:
"0615: T 99.8. HR 112. RR 26. O2 sat 94% on 4L NC. Patient awake and alert, watching cartoons. Father asleep in chair. Handoff to day shift given."
The official chart had a 06:15 note that said:
"0615: T 98.8. HR 104. RR 22. O2 sat 98% on 2L NC. Patient awake and alert. Handoff to day shift given."
The bedside chart had an attending physician note at 08:30 that said:
"0830: Patient had two oxygen desaturation events overnight (89% at 0315, 92% at 0440). Currently on 4L NC. Recommend continue antibiotics and oxygen. Not stable for discharge. Will reassess in 24 hours."
The official chart had an attending physician note at 08:30 that said:
"0830: Patient afebrile overnight. Currently on 2L NC. Recommend discharge today with outpatient follow-up. Stable for discharge."
Moreno set both charts down.
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She looked at the two notes for a long time.
Then she picked up her phone and she called the OSI — because the OSI was the agency that handled the medical record fraud cases at Naval Medical Center San Diego when the accused was a physician — and she said, "I have a case. It is not a big case. It is one patient and one chart and two notes. But I want you to look at it today. Because if this is what I think it is, it is not one patient. It is every patient who has been on this ward in the last year."
