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12 CA Hospitals Fined for Immediate Jeopardy Violations

Cheryl Clark, for HealthLeaders Media, September 8, 2011

8. At Riverside Community Hospital, Riverside, in Riverside County, a surgical team failed to detect and remove a 14-centimeter metal clamp from a patient's abdomen, state documents say.

The patient had come to the emergency room complaining of pain and underwent a colostomy, after which state documents say, "the operative/procedure note stated 'all lap and instrument counts were correct.' "

However, after the patient continued to have pain, and underwent a CT scan of the abdomen and pelvis some time after the surgery. That image indicated "a 14-cm metallic instrument, probably a hemostat, in the right lower quadrant.


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According to state documents, the patient "returned to the facility on....2009 for a colostomy takedown (13 days after Physician 4 was made aware of a retained foreign object in Patient 1's abdomen.)"

During the colostomy take-down, because of the patient's pain, an ultrasound of the gallbladder "unfortunately showed a large metal clamp left in the abdominal cavity," according to a hospital document quoted in the report.

An unspecified time later, the patient returned again for surgery, for the colostomy takedown and "removal of foreign body (metal clamp) with lysis of adhesions."

State documents say that Riverside's quality and safety vice president said "there was a disconnect between the facility staff and physicians involved in the surgery regarding reporting. The physicians were aware the clamp was not accounted for, however, did not report to facility Administration for follow-up."

"The facility was unable to determine who the scrub nurse or circulatory nurse was at the time of surgery or who was doing what in a point of time."

An RN who was said to be present during the initial instrument count "was relieved by another nurse, therefore she was not present during the final count."

Riverside was fined $50,000. This was Riverside's first penalty.

9. At Stanislaus Surgical Hospital, Modesto, in Stanislaus County, surgeons made a wrong site surgical incision on a patient's ankle, the result of the facility failing to "ensure the site of a surgical procedure was correct" before surgery, observe a time-out, or conduct other routine pre-surgical checks. "The staff failed to recognize the 'wrong site' had been readied for surgery," state documents say.

Stanislaus was fined $50,000. This was Stanislaus' first penalty.

10. At Sutter Delta Medical Center, Antioch, in Contra Costa County, a patient was not provided cardiac monitoring for potentially fatal dysrhythmias for more than 40 minutes, resulting in delay of cardiopulmonary resuscitation and cardiac arrest.

The patient "suffered irreversible anoxic brain injury...and died less than three days later when..removed from life support.

The patient, who entered the hospital's care through the ED, was transferred to a telemetry nursing unit, but 24 minutes after the patient was reported as alert and oriented, the patient was found unresponsive, not breathing.

"Review of the cardiac monitoring strips showed no recording of patient 1's heart rhythm for approximately 44 minutes," state documents indicate. Apparently, the patient was presumed to be on monitor standby, which may happen if the patient needs to go somewhere for tests. However no physician's order, which was required, was documented.

Sutter Delta was fined $50,000. This was Sutter's first penalty.

11. At Torrance Memorial Medical Center, Torrance, in Los Angeles County, a surgical team failed to account for a endoscopic anti-fog solution bottle, "which resulted in the retention of a foreign object," state documents show.

The patient later had another surgery some months later, "where they found and removed a foreign object from Patient 1's abdomen." The 2.75-inch device, also called a fog reduction endoscopic device, comes in custom packs and is used to keep the lens of the telescope from fogging.

State documents say an employee said, "Not all the items inside the custom packs were counted," although another item in the packs, a green sponge, was.

Torrance Memorial was fined $50,000. This was Torrance's first penalty.

12. At the University of California San Francisco Medical Center, San Francisco County, members of the surgical team failed to remove an 18 x 18 laparotomy sponge, the state says.

The hospital's medical director of perioperative services told state investigators that a nurse "did not scan one of the sponges" with the hospital's scanner system, "maybe the one that fell to the floor."

When one was missing, the nurse may have assumed the one on the floor was the missing one. "Since we started using the scanner, we have used 5 million sponges in the medical center and only lost one," the director told investigators. "The system works if the policy is followed.

UCSF was fined $50,000. This was UCSF's fifth penalty.

The documents referred to are available here under each named California county.


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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