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12 CA Hospitals Fined for Immediate Jeopardy Violations

 |  By cclark@healthleadersmedia.com  
   September 08, 2011

A dozen California hospitals must pay "immediate jeopardy" fines totaling $650,000 for safety lapses that caused death or harm to patients under their care, state health officials announced Wednesday.

Since legislation establishing these penalties took effect in 2009, 124 hospitals have received 198 fines totaling $6.8 million, said Pam Dickfoss, acting deputy director of the Center for Health Care Quality, California Department of Public Health.

Dickfoss added that in these three years, "the number of substantiated adverse events has declined by 12% since 2008.

"Though we don't have the analysis to say that these penalties are the reason for the decline, I think it's a combination of factors," she said during a news briefing. "These penalties have raised an awareness within the healthcare industry, and hospitals are working closely with us to incorporate policies and procedures to prevent them. It's our expectation these events will (continue to) decrease."


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Asked whether the fine amounts – which have since 2009 ranged between $50,000 to $100,000 depending on whether it's the hospital's first, second, or subsequent offense – are enough of an incentive for hospitals to be more careful, she said she thinks they are.

"I think (hospitals) take them very seriously," Dickfoss said, adding that the money collected so far, $4.6 million, goes into an account that can only be used for quality improvement activities. About $1 million of that has been earmarked for specific projects.

California's process and frequency of penalty assessment for state immediate jeopardy incidents is among the nation's toughest.

The 12 hospitals and the reasons for their immediate jeopardy penalties are listed as follows:

1. At Alameda Hospital, Alameda, in Alameda County, an older patient died, and six others were put in danger after being given excessive and increasing doses of fentanyl in patch form, state documents indicate.

Fentanyl, usually indicated to treat pain, was given to relieve the patient's respiratory distress although the drug is not indicated for that purpose, state documents indicate. Three other patients

Numerous preventive safeguards failed to prevent adverse events from fentanyl misuse. "All seven patients received fentanyl patches without a pharmacist's assessment of the appropriateness of the doses and establishing opiate tolerance," state health officials said. "This had the potential to expose patients to irreversible and potentially life threatening side effects, including respiratory depression and possibly death."


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Alameda was fined $50,000. This was Alameda's first penalty.

2. At Brotman Medical Center, Culver City, in Los Angeles County, according to the state's report, an 82-year-old patient with a history of falls and impaired mobility was left unsupervised, fell to the floor and later died after developing a subdural hematoma.

"The facility failed to assess, implement and update interventions of the nursing plan ...for fall prevention for Patient 1 and failed to follow its policy and procedure on falls prevention," state investigators said.

Brotman was fined $50,000. This was Brotman's second penalty.

3. At California Men's Colony, San Luis Obispo, in San Luis Obispo County, an institution for minimally and medium security risk prisoners, a 76-year-old inmate died after receiving another inmate/patient's methadone, records indicate.

The prison was fined $50,000. This was its first penalty.

4. At Dominican Hospital, Santa Cruz, in Santa Cruz County, state documents note that a testicular cancer patient received "an excessive amount of a chemotherapy medication (cisplatin), causing the patient's symptoms to worsen over the next five days.

According to state documents, the patient's primary oncologist "stated 'I discovered that I had transposed two numbers in calculating his chemotherapy doses, and thus, the patient had received 100 mg per meter squared per day of cisplatin instead of 20 mg. ... for the four days he was administered the chemotherapy."


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Dominican was fined $75,000. This was Dominican's third penalty.

5. At Emanuel Medical Center, Turlock, in Stanislaus County, the state's report describes a pneumonia patient who also had sepsis, received a central line catheter in the right femoral vein "without the benefit of written protocol. This failure resulted in a guide wire (a wire or spring used to introduce and guide the catheter into place, then removed) being left in Patient 1, and had the potential to cause physical harm from the guide wire itself."

The patient required a second procedure to remove the guide wire, but state documents said that it was "lost in the patient," and was found and removed through the superior vena cava," and pulled out through the groin.

"Medical doctor 1 acknowledged the guide wire should be held at all times during a central line placement (and...) stated he must have been distracted and accidently let go of the guide wire sometime during the process."

Emanuel was fined $75,000. This was Emanuel's second penalty

6. At Kaiser Foundation Hospital & Rehabilitation Center, Vallejo, in Solano County, a patient who underwent cataract surgery received a lens intended for another patient, the state found. "A second surgery was required to remove the wrong lens," state documents said, resulting in "increased risk for complications including infection, a second procedure, prolonged healing of the eye and patient discomfort.


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State documents said that the patient complained about the pain, saying it "felt like sand in his eye."

Kaiser Vallejo was fined $50,000. This was Kaiser's second penalty.

7. At Los Angeles County-University of Southern California Medical Center, Los Angeles, in Los Angeles County, a 48-year-old patient suffering severe burns over 32% of his body developed difficulty breathing and required endotracheal intubation after a certified registered nurse anesthetist placed the patient "under general anesthesia without consultation by the supervising physician," state documents said.

"This resulted in significant change to Patient A's neurological status after surgery" and "severe anoxic brain injury."

State documents said the patient had been assessed an anesthesia score of 4, indicating high risk for anesthesia, which could lead to death.

LA County hospital policy requires that CRNAs have physicians present for induction for all anesthesia, and if the faculty is busy with another case, permission to begin alone is required.

LA County was fined $50,000. This was LAC+USC's fourth penalty.

8. At Riverside Community Hospital, Riverside, in Riverside County, a surgical team failed to detect and remove a 14-centimeter metal clamp from a patient's abdomen, state documents say.

The patient had come to the emergency room complaining of pain and underwent a colostomy, after which state documents say, "the operative/procedure note stated 'all lap and instrument counts were correct.' "

However, after the patient continued to have pain, and underwent a CT scan of the abdomen and pelvis some time after the surgery. That image indicated "a 14-cm metallic instrument, probably a hemostat, in the right lower quadrant.


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According to state documents, the patient "returned to the facility on....2009 for a colostomy takedown (13 days after Physician 4 was made aware of a retained foreign object in Patient 1's abdomen.)"

During the colostomy take-down, because of the patient's pain, an ultrasound of the gallbladder "unfortunately showed a large metal clamp left in the abdominal cavity," according to a hospital document quoted in the report.

An unspecified time later, the patient returned again for surgery, for the colostomy takedown and "removal of foreign body (metal clamp) with lysis of adhesions."

State documents say that Riverside's quality and safety vice president said "there was a disconnect between the facility staff and physicians involved in the surgery regarding reporting. The physicians were aware the clamp was not accounted for, however, did not report to facility Administration for follow-up."

"The facility was unable to determine who the scrub nurse or circulatory nurse was at the time of surgery or who was doing what in a point of time."

An RN who was said to be present during the initial instrument count "was relieved by another nurse, therefore she was not present during the final count."

Riverside was fined $50,000. This was Riverside's first penalty.

9. At Stanislaus Surgical Hospital, Modesto, in Stanislaus County, surgeons made a wrong site surgical incision on a patient's ankle, the result of the facility failing to "ensure the site of a surgical procedure was correct" before surgery, observe a time-out, or conduct other routine pre-surgical checks. "The staff failed to recognize the 'wrong site' had been readied for surgery," state documents say.

Stanislaus was fined $50,000. This was Stanislaus' first penalty.

10. At Sutter Delta Medical Center, Antioch, in Contra Costa County, a patient was not provided cardiac monitoring for potentially fatal dysrhythmias for more than 40 minutes, resulting in delay of cardiopulmonary resuscitation and cardiac arrest.

The patient "suffered irreversible anoxic brain injury...and died less than three days later when..removed from life support.

The patient, who entered the hospital's care through the ED, was transferred to a telemetry nursing unit, but 24 minutes after the patient was reported as alert and oriented, the patient was found unresponsive, not breathing.

"Review of the cardiac monitoring strips showed no recording of patient 1's heart rhythm for approximately 44 minutes," state documents indicate. Apparently, the patient was presumed to be on monitor standby, which may happen if the patient needs to go somewhere for tests. However no physician's order, which was required, was documented.

Sutter Delta was fined $50,000. This was Sutter's first penalty.

11. At Torrance Memorial Medical Center, Torrance, in Los Angeles County, a surgical team failed to account for a endoscopic anti-fog solution bottle, "which resulted in the retention of a foreign object," state documents show.

The patient later had another surgery some months later, "where they found and removed a foreign object from Patient 1's abdomen." The 2.75-inch device, also called a fog reduction endoscopic device, comes in custom packs and is used to keep the lens of the telescope from fogging.

State documents say an employee said, "Not all the items inside the custom packs were counted," although another item in the packs, a green sponge, was.

Torrance Memorial was fined $50,000. This was Torrance's first penalty.

12. At the University of California San Francisco Medical Center, San Francisco County, members of the surgical team failed to remove an 18 x 18 laparotomy sponge, the state says.

The hospital's medical director of perioperative services told state investigators that a nurse "did not scan one of the sponges" with the hospital's scanner system, "maybe the one that fell to the floor."

When one was missing, the nurse may have assumed the one on the floor was the missing one. "Since we started using the scanner, we have used 5 million sponges in the medical center and only lost one," the director told investigators. "The system works if the policy is followed.

UCSF was fined $50,000. This was UCSF's fifth penalty.

The documents referred to are available here under each named California county.

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