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Immediate Jeopardy: 14 CA Hospitals Fined $850,000

Cheryl Clark, for HealthLeaders Media, December 12, 2011

Also, although the hospital had posted MIU visiting hours of 1 p.m. to 8 p.m., "the policy was not enforced. On the date of the abduction, the abductor was on the unit more than three hours before visiting hours were to start and was photographed by surveillance cameras" leaving with a large tote bag, but was not stopped or questioned. Also, the parking structure's attendant was not included in the personnel who were notified of an infant abduction.

"Fortunately, the abductor was unable to pay the parking fees before leaving the lot," and so the attendant noted the abductor's name and license plate number, which was used to locate the abductor and the baby later that evening. The hospital was fined $50,000. This was Santa Barbara Cottage's first penalty.

9. At Scripps Memorial Hospital, La Jolla, in San Diego County, a spine surgeon failed to remove a 2.5 cm temporary pin, and a fluoroscopy test prior to the patient leaving the operating room and two more X-rays failed to discover it. "According to the radiologists, they both believed the object to be part of the surgical hardware. The radiologists explained that many different types of procedures with many different types of hardware are performed at the facility."

Even though they noted the object in their review, they did not notify the surgeon "because they did not perceive the object as foreign but thought perhaps it was an unusual variant," according to state documents.

The patient "complained of discomfort throughout the evening following surgery," according to the state report. She "complained of feeling something stuck in her throat at 8:35 p.m., something moving in her neck at 9:30 p.m., and finally difficulty breathing at 10 p.m.," when the surgeon was notified and another X-ray was ordered, finally revealing the pin. The patient developed difficulty swallowing and hoarseness, but eventually recovered and was discharged.

Scripps was fined $100,000 because this incident was its sixth penalty.

10. At St. Jude Medical Center, Fullerton, in Orange County, a registered nurse who had not completed her three-month orientation misunderstood a physician to say that a patient required a morphine dose up to 20 mg. per hour intravenously, when the physician had merely ordered 2 mg. per hour—one-tenth the dose.

"The patient died within an hour of the morphine dose increase," according to the state's report. "The coroner's autopsy report revealed a blood level of morphine of 4.1 milligrams/liter and the corner determined the cause of death was due to 'acute morphine intoxication.'" According to the state's report, the hospital's administrative document indicated the nurse "admitted she did not know how to program a PCA (patient-controlled analgesia infusion) pump but did so anyway."

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