Medical Errors Draw Fines for 7 CA Hospitals
5. At Placentia Linda Hospital, Placentia, in Orange County, nursing and medical staff failed to report and the hospital failed to investigate an allegation of a witnessed sexual assault by medical doctor 2 (MD).
This "resulted in a subsequent sexual assault of Patient B by MD 2 and an ongoing threat of sexual assault to surgical patients by MD 2 over a period of approximately one year."
The problem became public when "a hospital transporter believed she witnessed an anesthesiologist fondle the breast(s) of a female patient under anesthesia for an outpatient surgical procedure" and reported it to hospital administration the following Monday.
State documents say that during an interview with the chief anesthesiologist, "it was revealed the allegation about MD 2 was not the first one reported to him.
Approximately a year ago, RN 1 had reported to him that ST 1, the surgical technician who assisted on the procedure, witnessed MD2 touch a female patient's genitals while performing a femoral nerve block…The Chief Anesthesiologist, wanting more concrete evidence, opted to monitor MD2's performance for any further sexual allegations," and did not report to the medical staff or administrators. "MD 2 was not confronted about the incident.
The penalty is $50,000. This is Placentia's first penalty.
6. At Santa Clara Valley Medical Center, San Jose, in Santa Clara County, staff failed to check a patient after noticing that his telemetry signals were not registering on the monitor, resulting in the patient suffering cardiac arrest and death.
After the monitor technician (MT) made a first announcement that the signals weren't registering, the second announcement wasn't made for another nine minutes.
"When the nurse did assess Patient 1, she found him lying on the floor, unresponsive, and disconnected from the cardiac monitor." Though the emergency team administered cardiopulmonary resuscitation and placed the patient on life support, he sustained brain injury. Life support was removed resulting in his death.
"When asked why there was a nine-minute delay from the first announcement to the second announcement, MT 1 stated she was occupied performing other tasks and lost track of time."
The 83-year-old patient had been brought to the hospital for treatment of a subarachnoid hemorrhage sustained after falling at home.
The penalty is $100,000. This is Santa Clara's third penalty.
7. At St. Mary's Medical Center, San Francisco, in San Francisco County, doctors failed to remove a 60-centimeter stiffener stylet, or guide wire, from a catheter that a surgeon inside a large vein of a chemotherapy patient, requiring another surgery.
Asked if he remembered pulling the guide wire out of the catheter after its placement, the surgeon told state investigators: "This does not follow my routine. I can't remember if I pulled the wire out or just cut across it."
A circulating nurse who was present during the procedure told state investigators "I get that wire when the surgeon pulls it out of the catheter and I put it in a bag. We don't count it like we do needles, sponges and knife blades.
The penalty is $75,000. This is St. Mary's second penalty.
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