Adverse Events Draw $775K in Fines at 9 CA Hospitals
The incident was complicated by the fact that a physician at a different hospital had originally diagnosed the patient, who had come to the emergency department with blood in his urine and where imaging at the first hospital revealed a suspected mass.
The physician at the first hospital referred the patient to Sharp, but erred in his report, identifying the left kidney as the location of the mass. Though the first physician corrected that report with an addendum the same day, noting the mass "is actually located within the **RIGHT** kidney," according to the state report, the surgeon at Sharp failed to see it.
The physician who performed the surgery at Sharp "recalled on the morning of the surgery he intended to access the images related to the case, but forgot the necessary log-on information needed to access the images remotely from" the second hospital, according to the state report.
As a result, "the images of Patient K, done at Hospital A, were not available to the surgical team at Hospital B. There were no x-rays, CT images, or CD disc to view in the operating room suite to confirm the correct side/site of the kidney tumor."
State investigators noted that "the members of the surgical team were asked if the missing radiological images constituted enough lack of information to stop the surgical procedure from moving forward. The surgical team members stated the absence of the images was brought to the attention of [the physician], and [that physician] made a decision to proceed with the scheduled surgery."
The patient underwent another surgery to remove the cancerous right kidney at a third hospital, and according to the patient's sister's report to the state "they were unable to save it. Which means he is on dialysis. Very sad."
The state report added, "The patient will need continuous on-going kidney dialysis to survive."
The penalty is $100,000. This is the hospital's fourth administrative penalty.
10. At St. Jude Medical Center, Fullerton, Orange County, a patient died after suffering an intracranial hemorrhage after a fall that staff knew he was at high risk for having.
According to the state report, "the patient showed impulsive behavior, did not use a call light, was using a walker for ambulation, had received a sedative-hypnotic, and had urgency when needing to use the restroom. There was no nursing supervision provided to the patient to ensure the patient was safe after the nursing staff had identified the patient had increased risk for falls and needed a sitter to prevent falls."
The penalty is $100,000. This is the hospital's sixth administrative penalty.
Immediate jeopardy fines in California are assessed as follows:
For incidents occurring after Jan. 1, 2009,
- The first carries a fine of $50,000;
- The second, $75,000;
- The third or subsequent violation by the same licensee, $100,000
Civil penalties for violations constituting immediate jeopardy in California may be viewed by county.
Incidents that occurred prior to 2009 are fined $25,000.
Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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