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12 CA Hospitals Fined for Immediate Jeopardy Violations

Cheryl Clark, for HealthLeaders Media, September 8, 2011

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.

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