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Medical Errors at 10 CA Hospitals Draw Fines of $625K

Cheryl Clark, for HealthLeaders Media, August 21, 2013

6. At Hollywood Presbyterian Medical Center, Los Angeles, Los Angeles
County, staff failed to implement its policies to refrain from feeding a stroke patient who was not able to cough on command and lacked swallowing reflex.

The patient, a 72-year-old female, came to the emergency room unable to talk or move, and a physician's exam determined she had "spasticity [stiffness/tightness] of the left side of her body, hemiparalysis [paralysis on one side of body] of the right side of the body."

According to the state report, a physician documented that despite the patient's inability to swallow, "Apparently, the patient was being fed and became hypoxic, respiratory failure and needed to be intubated last night." The patient had respiratory failure…most likely aspiration pneumonia..."

An interim chief nursing officer relayed to investigators that an employee "had fed the patient… (and) should not have fed the patient base on the facility's policy on swallowing screen assessment." The patient died.

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

7. At Desert Valley Hospital, Victorville, San Bernardino County, interventional cardiologists performed "emergency" coronary interventions such as stent placement and carotid angiograms, on patients contrary to the hospital's license, which requires that only patients with acute myocardial infarction or with hemodynamic instability or chest pain could undergo such procedures.

"According to the medical record, Patient 2, Patient 1, and Patient 3 did not present with a acute MI or hemodynamic instability or chest pain refractory [not responding] to medical treatment prior to having an intervention in the cardiac cath lab," the state report said.

For one of the three, a patient who had come to the hospital for an outpatient coronary angiogram and did not have pain, doctors placed a stent in the left anterior descending artery. "Subsequently, at 3:29 pm, patient 3 complained of chest pain, had a decrease in heart rate, then became hypotensive and was the subject of a code blue…Staff was unable to resuscitate the patient, who expired," state investigators said.

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

8. At Alta Bates Summit Medical Center, Oakland, in Alameda County, a patient died from a pulmonary embolus after a nurse mistakenly administered a feeding formula (Glucerna) into the patient's peripherally inserted central catheter (PICC) instead of the instead of a TPN (total parenteral nutrition) mixture.

According to the state report, a code blue was called. Afterwards, another nurse asked the administering nurse "what fluids she administered into Patient 1's PICC prior to the Code Blue and (the first nurse) responded, 'Just the TPN.' "

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