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12 More Hospitals Fined For Putting Patients In Immediate Jeopardy

Cheryl Clark, for HealthLeaders Media, September 4, 2009

The 12 California hospitals receiving the latest fines for putting patients in "immediate jeopardy" of harm or death include three that failed to remove sponges or towels from surgical patients, one where a psych tech repeatedly slapped an unconscious patient in the face in the belief he was "faking it," and another where staff failed to properly use restraints, resulting in a patient's critical fall.

Poor training of medication use resulted in a heparin overdose that caused a brain hemorrhage in a patient at a sixth facility while at a seventh hospital, managers failed to properly staff the intensive care unit, and a patient whose condition was quickly deteriorating was not adequately treated.

The penalties of $25,000 per hospital have been levied 98 times to 67 acute care facilities under a law that took effect in 2007. Only one other state, Minnesota, has a similar enforcement regulation, said Kathleen Billingsley, deputy director of the Center for Health Care Quality, California Department of Public Health.

Some have been levied fines as many as three times, and some for repeating similar violations.

"It is imperative that hospitals promptly respond to the issues identified by the Department of Public Health and I am pleased to say that the hospitals have done so," she said in a news conference Thursday. "Our goal . . . is to improve the quality of healthcare in all California hospitals."

However, Billingsley acknowledged that not all hospitals are accepting the fines. Of the 87 filed prior to this announcement, 63 have been paid, but 24 remain in appeal or settlement discussion. The state has been paid $1.8 million so far, an amount that includes fines for medical records breaches, such as those in the Octo-Mom disclosure at Kaiser Permanente in Bellflower.

The funds are to be used for special quality improvement projects, and suggestions from hospitals on how to use the money in specific demonstration projects are being solicited, Billingsley said.

"Under state law, hospitals are required to report to state officials any incident involving 28 "never" events, which include patient death or serious disability associated with a medication error, death or significant injury of a patient or staff member resulting from a physical assault, unintended retention of a foreign object in a patient after surgery or other procedure, patient death or serious disability associated with a fall or associated with the use of restraints or bedrails."

Last year, Governor Arnold Schwarzenegger signed legislation to significantly increase the fine for administrative penalties for violations or deficiencies constituting an immediate jeopardy to the health and safety of patients. The new law, which took effect Jan. 1, 2009, increases fines from $25,000 to $50,000 for the first violation. Incidents in this news release occurred in 2007 and 2008, before the new law took effect.

The following hospitals had these immediate jeopardy incidents:

1. At Southwest Healthcare Systems, Riverside, in Riverside County, hospital managers reportedly failed to have the minimum number of two adequately trained staff in intensive care unit beds, which had been converted from medical surgical/telemetry beds without approval. That resulted in inadequate care for at least one patient. An RN nurse told investigators, "It would be nice to have two nurses. Sometimes I have to stand by the door and yell out to get somebody to help me," noted the California Department of Public Health.

Also, since the bed had previously been used for medical surgical and telemetry, the medication and supplies were not allegedly sufficient for caring for a patient in ICU. The hospital, previously named Universal Health Services of Rancho Springs, has been fined twice before for failure to provide adequate on-call physician coverage and for failure to ensure proper food controls, according to the California Department of Public Health.

2. At Arrowhead Regional Medical Center, Colton, in San Bernardino County, a psych tech repeatedly slapped a patient in the face. The patient, who had self-inflicted cuts and was said to be a danger to himself, had passed out, but the psych tech told other techs and a charge nurse in the room, "he's faking it." Also, another psych tech who witnessed the incident said he didn't like what was happening, but "didn't feel comfortable approaching him (the first psych tech) because the few times I did he would just curse at me. The charge nurse was not going to talk to him either because he would do the same to her," reported the California Department of Public Health.

3. At Enloe Medical Center, Esplanade, in Butte County, an 82-year-old woman suffered an intracranial hemorrhage and left-side paralysis after a reported overdose of heparin by a staff person who lacked training in medication administration. Also, "the facility failed to identify the loss of the pharmacy's software system's ability to automatically access critical drug related laboratory values following a software update. The cumulative effects of these systemic problems resulted in the pharmacy's inability to provide pharmaceutical services and care in a safe and effective manner resulting in serious injury to patient 1 and posed a significant risk for injury or death to other patients," noted the California Department of Public Health.

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