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7 Hospitals Fined for Immediate Jeopardy Mistakes

Cheryl Clark, for HealthLeaders Media, April 14, 2010

California health officials Tuesday imposed "Immediate Jeopardy" fines totaling $475,000—including a $100,000 fine that is the highest so far—on seven California hospitals they said harmed patients or placed them at risk of harm because of avoidable mistakes in delivery of care.

According to state documents, a surgical team left a sponge inside a cancer patient—which went undiscovered for more than year—after her hysterectomy in San Diego. A doctor operated on the wrong knee on a patient in San Francisco. And a provider in Davis wrongly injected a patient with an iodine contrast agent to which she was allergic prior to administering a CT, causing her fatal respiratory arrest.

"In administering these administrative penalties, our goal is to improve the quality of healthcare in all California hospitals," said Kathleen Billingsley, deputy director for public health. She said money from the fines will be used to gather information "to determine how these violations and deficiencies can be decreased and eliminated over time."

The latest state fines bring the total assessed since 2007 to $4.225 million, of which $2.87 million has been collected so far. Billingsley said of 146 penalties, hospitals are appealing 37, but to date, no hearings have been held.

Under state law starting Jan 1 2009, hospital penalties were increased from $25,000 per incident. After that date, a hospital's first immediate jeopardy carries a $50,000 fine, the second carries a $75,000 penalty, and the third and subsequent incidents will cost $100,000 each until the hospital goes three years with no immediate jeopardy findings.

The seven hospital penalties announced Tuesday are:

1. Southwest Healthcare System in Murrieta received three fines—including one for $100,000—for alleged serious deficiencies state officials discovered there last year, bringing to six the total number of fines levied against Southwest since 2007, state documents say.

Southwest was fined $50,000 or an event last August in which the hospital failed to properly assess newborns for risk of hyperbilirubinemia, or jaundice, before they were discharged.

They were fined $75,000 after a repeat investigation in September found that babies with the condition were still being sent home without proper discharge planning.

They were also fined $100,000 for an incident, also in September, after state investigators found that levels of humidity were not kept low enough in the surgical obstetric unit while C-sections were being performed, "creating a risk for a fire to start during the procedures" and posing a risk to the mothers and babies, state documents said.

During C-sections, surgeons use devices that cause sparks in an effort to stop bleeding, procedures that take place in a suite right next to the newborn nursery, labor and delivery area, and triage rooms, state documents said. "If a fire broke out in the (C-section operating room) it could spread to those rooms."

Informed by a reporter during a news conference that Southwest was claiming the problems would be alleviated if the state would approve the hospital's expansion plans, Billingsley said, "It's important to note that Southwest has had a prolonged history of noncompliance that includes many issues that are by no means related to its space," Billingsley said.

"You will notice there have been situations where there have been inadequate care problems following discharge of newborns. Those are not related to expanded space.

"We believe that citizens of California are entitled to obtain healthcare services from a hospital that meets the minimum level of required state standards and we encourage this hospital to not only correct this, but any system wide issues that will allow us to approve this application."

Billingsley added that "no other hospital in California has received more than four [immediate jeopardy penalties] with the exception of Southwest."

In a statement issued Tuesday, Southwest officials denied the state's allegations and intend to appeal these as well as the three issued previously. Hospital officials insist that the incidents did not meet the criteria for immediate jeopardy "because they neither caused, nor were likely to cause, serious injury or death to any patient in light of the facts..."

The hospital denies that humidity levels were unsafe, and denies that newborns were not properly assessed and unsafely discharged.

"In the three cases cited by CDPH, all newborns were tested to determine the level of bilirubin before they were discharged from the hospital, and nursing staff reported those test results to the newborns' pediatricians. In all three cases, the attending pediatricians made clinical decisions about what additional tests and treatments to order and how quickly to see their patients after discharge; such decisions belong to a patient's physician, not to the hospital," according to the hospital.

2. Scripps Mercy Hospital, San Diego, was fined $25,000 because a surgical sponge was unintentionally left in a cancer patient's abdomen during her December 2007 hysterectomy. During a follow-up MRI scan more than a year later, the radiologist reported a mass that was possibly a foreign body, which was reported to the patient's oncologist, said the state.

The patient complained of hip and back pain "and a second abdominal operation was performed . . . to search for the foreign body, but no foreign body was found at that time. A subsequent abdominal X-ray report ... and surgical procedure report . . . continued to document the presence of a foreign body" in the patient's pelvis, said the state.

The sponge was finally removed in June 2009.

"These violations resulted in injury and harm to [the patient] when she required a third surgical operation to remove a retained 4 inch by 4 inch surgical sponge from her abdominal/pelvic cavity, approximately one-and-a-half years following her radical hysterectomy procedure."

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