California health officials Tuesday imposed "Immediate Jeopardy" fines totaling $475,000—including a $100,000 fine that is the highest so far—on seven California hospitals they said harmed patients or placed them at risk of harm because of avoidable mistakes in delivery of care.
According to state documents, a surgical team left a sponge inside a cancer patient—which went undiscovered for more than year—after her hysterectomy in San Diego. A doctor operated on the wrong knee on a patient in San Francisco. And a provider in Davis wrongly injected a patient with an iodine contrast agent to which she was allergic prior to administering a CT, causing her fatal respiratory arrest.
"In administering these administrative penalties, our goal is to improve the quality of healthcare in all California hospitals," said Kathleen Billingsley, deputy director for public health. She said money from the fines will be used to gather information "to determine how these violations and deficiencies can be decreased and eliminated over time."
The latest state fines bring the total assessed since 2007 to $4.225 million, of which $2.87 million has been collected so far. Billingsley said of 146 penalties, hospitals are appealing 37, but to date, no hearings have been held.
Under state law starting Jan 1 2009, hospital penalties were increased from $25,000 per incident. After that date, a hospital's first immediate jeopardy carries a $50,000 fine, the second carries a $75,000 penalty, and the third and subsequent incidents will cost $100,000 each until the hospital goes three years with no immediate jeopardy findings.
The seven hospital penalties announced Tuesday are:
1. Southwest Healthcare System in Murrieta received three fines—including one for $100,000—for alleged serious deficiencies state officials discovered there last year, bringing to six the total number of fines levied against Southwest since 2007, state documents say.
Southwest was fined $50,000 or an event last August in which the hospital failed to properly assess newborns for risk of hyperbilirubinemia, or jaundice, before they were discharged.
They were fined $75,000 after a repeat investigation in September found that babies with the condition were still being sent home without proper discharge planning.
They were also fined $100,000 for an incident, also in September, after state investigators found that levels of humidity were not kept low enough in the surgical obstetric unit while C-sections were being performed, "creating a risk for a fire to start during the procedures" and posing a risk to the mothers and babies, state documents said.
During C-sections, surgeons use devices that cause sparks in an effort to stop bleeding, procedures that take place in a suite right next to the newborn nursery, labor and delivery area, and triage rooms, state documents said. "If a fire broke out in the (C-section operating room) it could spread to those rooms."
Informed by a reporter during a news conference that Southwest was claiming the problems would be alleviated if the state would approve the hospital's expansion plans, Billingsley said, "It's important to note that Southwest has had a prolonged history of noncompliance that includes many issues that are by no means related to its space," Billingsley said.
"You will notice there have been situations where there have been inadequate care problems following discharge of newborns. Those are not related to expanded space.
"We believe that citizens of California are entitled to obtain healthcare services from a hospital that meets the minimum level of required state standards and we encourage this hospital to not only correct this, but any system wide issues that will allow us to approve this application."
Billingsley added that "no other hospital in California has received more than four [immediate jeopardy penalties] with the exception of Southwest."
In a statement issued Tuesday, Southwest officials denied the state's allegations and intend to appeal these as well as the three issued previously. Hospital officials insist that the incidents did not meet the criteria for immediate jeopardy "because they neither caused, nor were likely to cause, serious injury or death to any patient in light of the facts..."
The hospital denies that humidity levels were unsafe, and denies that newborns were not properly assessed and unsafely discharged.
"In the three cases cited by CDPH, all newborns were tested to determine the level of bilirubin before they were discharged from the hospital, and nursing staff reported those test results to the newborns' pediatricians. In all three cases, the attending pediatricians made clinical decisions about what additional tests and treatments to order and how quickly to see their patients after discharge; such decisions belong to a patient's physician, not to the hospital," according to the hospital.
2. Scripps Mercy Hospital, San Diego, was fined $25,000 because a surgical sponge was unintentionally left in a cancer patient's abdomen during her December 2007 hysterectomy. During a follow-up MRI scan more than a year later, the radiologist reported a mass that was possibly a foreign body, which was reported to the patient's oncologist, said the state.
The patient complained of hip and back pain "and a second abdominal operation was performed . . . to search for the foreign body, but no foreign body was found at that time. A subsequent abdominal X-ray report ... and surgical procedure report . . . continued to document the presence of a foreign body" in the patient's pelvis, said the state.
The sponge was finally removed in June 2009.
"These violations resulted in injury and harm to [the patient] when she required a third surgical operation to remove a retained 4 inch by 4 inch surgical sponge from her abdominal/pelvic cavity, approximately one-and-a-half years following her radical hysterectomy procedure."
Scripps officials said that since the incident, they have reviewed all surgical cases regarding surgical counts and reviewed competency training for nurses and scrub techs.
3. California Pacific Medical Center, Pacific Campus in San Francisco, was fined $25,000 because a surgeon performed arthroscopy on a patient's right knee instead of the left, as intended. "They should have done a time out [a period prior to surgery for checking the right patient, right body part] but they didn't do one, they went straight into the procedure," said the state.
"When the surgeon realized the mistake, he proceeded to do an arthroscopy of both knees even though the consent form was for the left knee only."
4. Sutter Davis Hospital was fined $25,000 for a 2008 incident in which a patient with serious airway diseases and who had neck pain and swelling was administered an iodine contrast material prior to conducting a CT scan.
According to state documents, the patient had a history of iodine allergy, but her medical records were not checked beforehand, nor was a physician in the room as she was undergoing the scan, said the state.
During the CT procedure, "the nurse observed [the patient] having some type of distress, the nurse and technician attempted to reposition the arms, but [the patient's] oxygen level and blood pressure fell and a Code Blue emergency was called," according to state documents.
"Within minutes of receiving the contrast injection, [the patient] experienced breathing difficulty, low heart rate and low blood pressure requiring rescue interventions and interrupted the imaging studies. [The patient] did not respond to stabilizing treatments over the next two hours and expired in the radiology suite."
5. Kaiser Foundation Hospital in Fontana also received two penalties, the first for $25,000 for an incident in 2008 in which a patient undergoing surgery to remove orthopedic hardware from his left knee received first, second, and degree burns from a "triangle" device used to position the knee, according to officials.
After the patient went home after surgery "he felt pain behind his left knee, removed his bandages himself at home and saw blisters," said the state.
The triangle device had been sterilized, but was still too hot when it was placed, according to state documents.
"There was no procedure listed on how to protect a patient from burns or on how to determine if the flash sterilized instruments were cool enough to be used on a patient," the state documents said.
The Fontana hospital was also fined $50,000 after surgeons in 2009 reportedly left a sponge inside a patient despite the fact that the surgical count of sponges and other surgical devices was correct. It was found only because a physician "had an uneasy feeling there was a retained sponge." The item was detected by X-ray and required a second surgery for removal.
6. St. Joseph's Hospital in Orange was fined $50,000 because a double pneumonia patient who required oxygen was transported for an ultrasound test without a tank containing sufficient amount of oxygen for the amount of time required. "While in the [ultrasound] department, the patient had a respiratory arrest and died," state documents said. "It was observed at the time of the arrest the oxygen tank connected to the patient was empty."
"The patient was transported to the radiology department without a completed and signed checklist showing the patient was stable for transfer," said the state.
Additionally, the state report said, "The hospital chart showed that for the size of the portable oxygen tank used to transport the patient, that on a full oxygen tank at the rate the patient was receiving oxygen, 15 liters per minute, the tank could supply oxygen to the patient for about 45 minutes."
However, the state document shows, the patient was waiting in the radiology room for 60 minutes. The ultrasound technician assistant transported the patient back to their room ... the portable oxygen tank was empty, the patient was observed not to be breathing.
7. St. Bernadine Medical Center in San Bernardino was fined $50,000 for a 2009 incident in which doctors failed to remove a blade extender tip of a Bullard laryngoscope that was used for an exam of the larynx.
"The retention of the blade extender tip in [the patient's] airway had the potential to result in imminent danger due to occlusion of the airway, as a result of aspiration of the blade extender tip," according to the state's report.
The patient had undergone an outpatient lap cholecystectomy. "During a routine follow-up phone call to the patient . . . [the patient] informed the hospital staff that she had 'coughed up a piece of white plastic,'" later identified by the anesthesiologist as the extender tip of the laryngoscope he had used to intubate the patient, the documents said.