Guam panel facing complaint over nurses' botched job that led to a 5-year-old's death in 2018
- Admin
- 23 minutes ago
- 3 min read
By Jayvee Vallejera
Two nurses provided substandard care that resulted in the death of 5-year-old Asher Dean Lubofsky at Guam Memorial Hospital six years ago, but no one was held accountable for the fatal failure of service, according to the patient's father, who filed a complaint against a regulatory panel.
David Lubofsky is protesting the Guam Board of Nurse Examiners' decision to close his case against two hospital nurses—allegedly in response to the GMH administrator's request—despite instances of failure documented by different agencies.
Lubofsky said the board’s dismissal of his complaint against the two nurses violated the Nurse Practice Act, the Sunshine Act and the Administrative Rules of the Guam Board of Nurse Examiners.
The board identified the nurses only by their last names, Echipare and Mercado. Lubofsky alleged that the board was deliberately hiding the nurses' full identities.
“I filed this complaint because families deserve transparency, accountability, and a regulatory system that protects the public. Asher deserved better. Guam deserves better," Lubofsky said.
The Pacific Island Times reached out to the nurse board and GMH for comments but has not received a response as of this writing.
Asher Lubofksy died at GMH on Oct. 31, 2018.
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Lubofsky said it took the board nearly six years to act on his case, only to close it on May 21 this year without any resolution and without notifying him as the complainant.
The Nurse Practice Act mandates the board to issue clear findings of fact, clear conclusions of law and clear disciplinary determinations. Under the Sunshine Act, the board is required to disclose final actions and maintain transparency in all public matters and under the board’s own administrative rules, the complainant must be notified of the final decision.
“None of these requirements were met,” Lubofsky said.
According to his complaint, both the Center for Medicare and Medicaid Services and the Guam Health Professional Licensing & EMS Office have documented instances of failures in providing care to his son. The board’s own legal nurse consultant, a pediatric nurse practitioner at the Boston Children’s Hospital, also documented failures.
“Nurses Echipare and Mercado did not adhere to the standard of care. Their decisions directly led to the child’s death," states the report commissioned by the Health Professional Licensing Office.
Despite these findings, the board closed his complaint allegedly in response to the GMH administrator's request, which Lubofsky said was a conflict of interest.
Lubofsky noted that since GMH had already entered into a wrongful death settlement in the case, it had every incentive to push for the closure of his complaint.
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“Yet the board accepted GMH’s request and used GMH’s own language to justify closing the case, stating that ‘all corrective action plans have been completed’ and that ‘the identified issues were non-recurring.’ These phrases came from GMH, not from any independent nursing standard review,” Lubofsky said.
He also took issue with the board’s comments during the May board meeting, where it said the nurses had already “served their time” and “suffered enough.”
This implies that the two nurses have already been disciplined, he said. Yet the board has not revealed when it happened.
“If discipline was imposed, it must be disclosed. No disclosure was made. No notice was provided. No determination was issued," he said.
Lubofsky said the board refused to answer basic questions in its response to his Freedom of Information Act request.
“How can the people of Guam be protected if it takes six years for the regulatory board to do their job and the very hospital who settled a wrongful death claim can influence them to drop a standard of care investigation against their own nursing staff,” he said.
Lubofsky's separate complaint against Dr. Dennis Sarmiento, the GMH physician who attended to his son at the hospital, has also been closed.
However, Lubofsky said he dos not know whether Sarmiento has been reported as required to the National Practitioner Data Bank or if this information is included in his online profile, as required by law.
Lubofsky has filed a Freedom of Information Act request to seek relevant information about Sarmiento's case.
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