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13 Hospitals Fined for Immediate Jeopardy Violations in CA

Cheryl Clark, for HealthLeaders Media, June 4, 2012

California health officials are currently working to increase the penalty amounts to a maximum of $125,000. The revisions also would allow regulators more flexibility to take into consideration the patient's physical and mental status, the probability and severity of the risk to the patient, actual financial harm, the facility's history of regulatory compliance, factors beyond the facility's control, the willfulness of the violation and the extent to which the facility detected the problem and took steps to correct it.

Rogers said that retained foreign objects continue to be the most common reason for immediate jeopardy penalties against hospitals, accounting for 26%. Those are followed by medication errors, 24%; patient safety issues, 17.8%; and patient care issues, 17.4%.

According to state documents, which can be found on the state website by county, these are some details of each incident:

1. At Kaiser Foundation Hospital in Oakland/Richmond, in Alameda County, a telemetry unit patient died after his cardiac monitor sent alarms to the nurse's paging device indicating rapid heart rates, and a notification of a low battery, "neither of which was responded to."

Eventually, the alarm changed to "replace battery," which means 'no monitoring is occurring and the battery should be replaced immediately.

By the time the "replace battery" notification was acted on, the patient "was found pulseless, unresponsive, and in cardiac arrest."

"Approximately six minutes passed between when the monitoring system could not analyze Patient A's cardiac rhythm and when RN2 called the emergency code to attempt resuscitation of the patient."

The incident was Kaiser Oakland's second penalty and resulted in a $75,000 fine. 

2. At Community Regional Medical Center, Fresno, in Fresno County, a nurse administered 50 times the physician's ordered amount of heparin to a patient, causing an intracranial bleed resulting in death.

According to the hospital's risk manager, "the IR nurse programmed the pump (equipment used to precisely administer IV medication) to administer 300 ml an hour instead of 300 units an hour." Also, the programming nurse had not programmed the pump to use guardrails, built in safety mechanisms that send alerts when safety parameters of high-risk medications like heparin aren't met.

The incident was Community Regional's first penalty and resulted in a $50,000 fine. 

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