After he fell, however, a physician's assistant, who noticed him having a hard time breathing did not call a physician.
The patient also complained of chest and shoulder pain, and had bruising on his chest. An autopsy requested by the family found that the patient had "rib fractures, hemoperitoneum, and retroperitoneal hemorrhage due to blunt force injury of torso" with a contributing factor of advanced metastatic prostate cancer.
Penalty: $75,000. This is the hospital's third penalty.
7. At Palomar Health, Downtown Campus, Escondido, in San Diego County, providers failed to prevent a patient from falling and fatally injuring his head in the intermediate care unit. "The fall resulted in bleeding in the brain, coma, and eventual withdrawal of life support and ultimately the death of Patient A," state investigators wrote.
According to the report, the patient had shown signs of alcohol withdrawal, and although seizure and fall precautions were ordered, staff did not prevent him from getting out of bed.
According to a nurse who witnessed the patient, "he took the entire tab alarm (a device connected to the patient's clothing and bed that emits a loud noise when it becomes detached) unit with him so that the alarm would not disconnect from his person, and therefore, no alarm would sound."
Just prior to the patient's fall, he demonstrated to a nurse assigned to his care that "he knew how to take the bed alarm off without the alarm sounding." After leaving the room, caregivers "heard a loud 'thud' " and the patient was bleeding from his head and his nose, later diagnosed as a subdural hematoma. He later died.
Penalty: $100,000. This is the hospital's third penalty.
8. At Marin General Hospital, Greenbrae, in Marin County, staff administered an anti-hypertension medication, Labetalol, to a patient with sepsis instead of Ceftriaxone, the prescribed antibiotic, "which resulted in renal failure and dry gangrene of all ten toes and two fingers, and contributed to (the patient's) death," investigators wrote.
According to the report, a licensed nurse "had pulled the incorrect medication from the Automated Drug Cabinet" resulting in a long period of low blood pressure, ischemic hepatitis, and impending gangrene.