The California Department of Public Health (CDPH) announced this week that it had fined 12 hospitals a total of $775,000 for incidents, and like the list released last February, it included safety violations that resulted in serious injury and death.
Fines ranging from $50,000 to $100,000 were meted out to medical centers in nine counties for incidents including the improper administering of medication tubes, surgical materials left behind in a patient and a burned baby.
Some of the cases are old—one dates back to 2011—but have only recently been closed.
California Pacific Medical Center-Pacific Campus Hospital, San Francisco—The patient went in for a hysterectomy but ended up in the emergency room with abdominal pains when a Jackson Pratt drain bulb was inadvertently left in her vagina. Doctors removed the bulb and gave her antibiotics. There was some question (pdf) about whether the surgeon was the responsible party and/or the nurses for not counting surgical items. It was the hospital’s fifth “Immediate Jeopardy” administrative penalty. $75,000
Community Hospital of the Monterey Peninsula—A woman with a history of high blood pressure, smoking and kidney cancer, was admitted for elective surgery. The operation was a success, but the patient died. Procedures for handling medications were not followed (pdf). Shortly after surgery a nurse administered Neo-Synephrine to the “already hypertensive patient with a fresh carotid artery patch without an order.” The patient expired 11 days later. $50,000
Desert Valley Hospital, Victorville—A local prisoner was brought to the hospital with chest pains after a beating. He was treated for a broken rib and sent back to prison. Ten days later he returned with fluid in his chest. It was not considered an emergency (pdf). The doctor inserted a tube in the right side. Oops. X-ray was read backward. The tube was reinserted on the left. There was some question if the prisoner gave signed consent for the tube. He was shackled. It may have been a verbal OK. Procedures to avoid wrong-site surgery were not followed. $50,000
Glenn Medical Center, Willows, Glenn County—A pregnant woman who spoke no English admitted with a pain near her liver. Through an interpreter, she spoke of having eaten hot peppers and a meat sandwich. There was no evidence that basic tests, like reflexes and fetal monitoring, were performed. The doctor did not take a urine sample for testing and sent her home. She returned to the hospital in an ambulance and began having seizures. The baby was stillborn. The patient had Preeclampsia (pdf), a complication of pregnancy, and the doctor should have known. $50,000
Kaiser Foundation Hospital, San Diego—The temperature of a premature newborn baby rose to 107.2 degrees while under the radiant heat warmer. There were body burns from the heating lamp, which had not been set on “baby mode.” The incident was not initially reported (pdf) to the CDPH because the burns were not considered a “serious disability.” $75,000
Marin General Hospital, Greenbrae—A patient successfully underwent cranial surgery and two days later underwent a second successful surgery to remove a disposable surgical clip (pdf) that shouldn’t have been left behind. The operating room director said the hospital did not count disposable neuro scalp clips post-surgery as a matter of course. Any procedure that doesn’t account for clips left in craniums is almost by definition deficient. It was the hospital’s fifth “Immediate Jeopardy” administrative penalty. $100,000
Mercy Medical Center, Merced—A patient admitted to the emergency room with significant lower abdominal pain was given 20 mg of Dilaudid in a 24-hour period. That’s too much (pdf) without close monitoring. It killed him. It was unclear if anyone looked in on him in the four hours before the last dose of Dilaudid was administered and he was found unresponsive in bed. It was the hospital’s third “Immediate Jeopardy” administrative penalty. $100,000
Orange Coast Memorial Medical Center, Fountain Valley—A woman suffering with stroke symptoms was admitted and promptly started on intravenous t-PA at double the manufacturer’s recommended dose (pdf). The doctor and the physician should have consulted more closely on tapering the dose to the patient’s lighter weight. The patient died. $75,000
Redlands Community Hospital, San Bernardino County—Surgery to replace a patient’s Cardiovert-Defibrillator (AICD) generator was successful, but recovery did not go smoothly. A surgical sponge (pdf) inadvertently left inside the patient caused an infection and erosion of the chest wall until it protruded through the skin—six months later. A doctor pulled out some, but not all of the sponge, and scheduled surgery for later in the week. The generator was removed but could not be replaced for six months to allow healing. The patient had to wear a special LifeVest 24/7 with daily intravenous treatment and weekly lab tests. $50,000
San Diego County Psychiatric Hospital—A man diagnosed with psychotic disorder and chronic schizoaffective disorder was shouting at people, demanding medication and tussling with employees. But when finally ordered to return to his room he did so. But instead of personnel backing off, they followed him to the room where a struggle ensued that broke the patient’s arm (pdf). That was deemed “poor judgment.” $50,000
Scripps Mercy Hospital, Chula Vista, San Diego County—A patient was admitted to the hospital with problems including acute renal failure and a high potassium level (pdf). Medication prescribed for the latter was not administered. Later, a nurse noticed the high potassium level and tried to call another doctor, who did not respond. The patient died. $50,000
Seton Medical Center, Daly City—A woman known to be susceptible to falls fell in the hospital shower (pdf) after being admitted with congestive heart failure. The staff picked her off the floor, checked her vital signs, noted the bump on her head and carried on. The next day she was seen walking funny and two days later she was dead. There are procedures for dealing with patients who have fallen and they were not followed. $50,000
–Ken Broder
To Learn More:
DPH Fines 12 California Hospitals $750K for Adverse Events (CaliforniaHealthline)
SD Hospitals Fined for Dangerous Care (by Paul Sisson, U-T San Diego)
California Department of Public Health Issues Penalties to 12 Hospitals (California Department of Public Health)
10 California Hospitals Penalized $700,000 for Botched Care (by Ken Broder, AllGov California)