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Immediate Jeopardy Fines for 12 California Hospitals

Cheryl Clark, for HealthLeaders Media, December 21, 2012

4. At Kaiser Foundation Hospital–South Bay, Harbor City, Los Angeles County, a patient admitted to repair his gastrointestinal tract bled to death when he received the anticoagulant Activase instead of the coagulation drug Activated Factor VII, which the surgeon requested.

A certified registered nurse anesthetist told investigators he was handed a bottle of medication by another physician and "put his trust in (my) supervisor and took the bottle of medication and administered the drug."

He said he "assumed it was the correct medication." The other physician who gave him the drug said he "did not read the medication label and did not verify the medication name."

State investigators said, "unfortunately, he did not do what he commonly practiced."

The penalty is $50,000. This is the hospital's first penalty.

5. At Kaweah Delta Medical Center, Visalia, Tulare County, two physicians neglected to rescue a woman who began bleeding profusely after a laceration during birth, and ultimately died from loss of blood.

The doctors failed to call for expert backup, and delayed a request for the rapid response team, as the woman bled for more than an hour.

One of the physicians, identified as "MD 2," told investigators "she did not keep track of the amounts of fluid and/or blood loss, vital signs, amount of urine output, and the amount of fluids given. When asked what she would have done differently, MD 2 stated, in retrospect, she should have called for assistance.

The penalty is $50,000. This is the hospital's first penalty.

6. In a second incident at Kaweah Delta Medical Center, Visalia, Tulare County, a patient died after being admitted with abdominal pain and underwent removal of the pancreas, which can lead to irregular glucose levels, diabetes, and mal-absorption of food.

After parenteral nutrition was stopped, physicians apparently neglected to adequately check glucose levels, and the patient went into a hypoglycemic coma, which was mistaken for a stroke.

The rapid response team was called but was not given information about the patient's pancreas removal. The team informed the family that the patient had a stroke, but no providers had checked the ordered CT.

The family was notified and informed that "death is imminent," and thus patient's code status was changed to "do not resuscitate."

"The facility failed to recognize the need to taper the TPN (parenteral nutrition), monitor blood glucose levels after the TPN was stopped, failed to assess, develop, and implement appropriate interventions, failed to pass on correct information due to a wrong assessment, the (rapid response team) failed to get sufficient Patient history for a proper assessment, and there was no advocacy for the patient from the (response team) to activate the team, and resulted in the death of the patient.”

The penalty is $75,000. This is the hospital's second penalty.

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