The most recent round of administrative penalties for hospital deficiencies constituting immediate jeopardy includes two patient falls resulting in deaths, a wrong-site surgery, and a retained surgical object.
At Sharp Memorial Hospital in San Diego, a surgical team took out a man's healthy left kidney instead of his cancerous right one because the hospital didn't make imaging studies viewable in the operating room and because the surgeon "forgot" how to log-in to see them before cutting into the patient.
At Antelope Valley Hospital in Lancaster, a patient returned to the emergency department three times before doctors realized they had forgotten to remove a 9 x 6-inch surgical device. According to state officials, the device was not included in the instrument count.
And at Community Regional Medical Center in Fresno, a surgeon left the OR after instructing a physician's assistant to finish the surgery, which the assistant was not trained to complete. The patient suffered major blood loss, cardiac arrest, and loss of oxygen to the brain. At the completion of a state investigation, the patient remained on life support.
These major adverse events in California hospitals are among 10 detailed in state documents accompanying $775,000 in administrative penalties to these hospitals, which state officials announced last week. The fines are assessed once state investigators determine that lapses in regulatory compliance caused or likely caused serious injury or death to a patient.
Since these penalties began in 2007, the state had issued 295 penalties to more than 155 of the state's 400 acute care facilities, according to a statement issued Thursday by the California Department of Public Health.
Including the latest round of penalties, the state has assessed $13.3 million in fines and has collected $10.1 million. Most of the $3.2 million not yet collected is under appeal by the hospitals that dispute the state's findings.
The funds are to be used for programs to improve healthcare safety.
In a phone interview Thursday, Debby Rogers, deputy director for the state Department of Public Health's Center for Healthcare Quality, refused to comment on any particular hospital's harmful event, but acknowledged that some incidents are more serious than others.
New regulations due to take effect by the end of the year, will allow the state to consider how much patient harm was done "and how widespread inside the hospital a particularly deficiency is."
"We feel strongly that publicizing these deficiencies helps hold these facilities accountable but it also empowers consumers to speak to their providers to put protections in place so something like this doesn't happen," Rogers said.
The incidents, with links to related documents are as follows:
1. At Alvarado Hospital Medical Center, San Diego, San Diego County, a patient admitted from a nursing home because she had fallen, died from bleeding in the brain caused by a subsequent fall while in the hospital. A nurse had turned off the patient's fall alarm to allow her to sit on the edge of her bed, as she had asked.
A second nurse, one of the first responders, said "he heard a loud 'crashing' sound" and found the patient on the floor with a pool of blood beneath her head.
The penalty is $50,000. This is the hospital's first administrative penalty.
2. At Antelope Valley Hospital, Lancaster, Los Angeles County, a patient discharged from the hospital after a colectomy returned three times for emergency department care because of pain before a forgotten surgical object was discovered in his abdomen.
He was sent home with pain medication the first time and given a groin ultrasound and pain medication before being sent home the second time. On his third visit to an emergency department, which was not named in the report, he was given a CT that revealed a retained surgical device.
A subsequent laparotomy removed a Glassman viscera retainer or "Fish" device measuring 9 inches by 6 inches, with a 9-inch attached string connected to a ring two inches in diameter. According to the website of the manufacturer, AdeptMed International, the ring "is an effective indicator of a retained instrument."
According to the state's report, the routine surgical count did not include the device because it was a "miscellaneous" item and not part of the surgical tray. The report does not detail how long the patient was in pain, only that he had "been suffering of abdominal pain for a while now" before the device was discovered.
State investigators said they documented the retained surgical object with an unannounced visit in response to an "entity reported" incident.
The penalty is $50,000. This is the hospital's first administrative penalty.
3. At Community Regional Medical Center, Fresno, Fresno County, a patient admitted for ascending aortic aneurysm repair suffered massive blood loss, cardiac arrest, and loss of oxygen to the brain after the heart surgeon left the operating room prior to the closure of the patient's chest during open heart surgery.
The surgeon instead directed a physician's assistant "to be left in charge, an individual not qualified to be left in charge of the cardiovascular surgery."
State investigators said the patient's loss of blood "required reopening the chest and manual massage of the heart." The patient was subsequently placed on life support.
Asked for an explanation, the surgeon said he had allowed the physician's assistant "to practice above her privilege card as 'she was preparing for an advanced quality practice exam and for that, she needed so many cases with opening and closing the chest and to cannulate the heart." The surgeon said he had always been there when she did this procedure "until this time."
State investigators wrote that the incident was reported through "an anonymous complaint," suggesting that the hospital may not have properly reported the incident as required by law.
The penalty is $75,000. This is the hospital's second administrative penalty.
4. Also at Community Regional Medical Center, Fresno, Fresno County, a patient had to undergo surgery and suffered paralysis of both legs after a physician told a physician's assistant to remove an epidural catheter, a procedure "neither was privileged (to perform)."
The patient had agreed to a procedure in which pain medication is injected into the epidural space in the lower back.
The patient was on Lovenox, a blood thinner, which complicated the case because according to the medication packaging, "epidural catheters were not to be removed when patients were being treated with blood thinners because of the risk of uncontrolled localized bleeding."
That removal led to the patient developing an epidural hematoma, which required surgery. The surgery resulted in the patient's lower limb paralysis.
The penalty is $100,000. This is the hospital's third administrative penalty.
5. LAC/Harbor-UCLA Medical Center, Torrance, Los Angeles County, a patient lost a great deal of blood, suffered altered mental status and died after the hospital team failed to perform current lab studies prior to the patient's scheduled knee replacement surgery.
According to the state's report, the patient's lab work and other testing was done five months prior to the surgery. In the interval, other operations and infections "had resulted in considerable distortion of the anatomy," which extended the duration of surgery to more than five hours. During that time the patient lost a critical amount of blood.
The hospital was also faulted because the surgical team failed to pre-order units of blood, and the hospital's blood bank was unable to emergently deliver sufficient amounts of blood to keep the patient alive. State investigators were told that the surgery was not supposed to require blood transfusion because a tourniquet was being used.
Records indicated that the surgeon had "completely transected" the patient's popliteal artery, which supplies blood to the knee joint and muscles in the upper and lower leg, in at least two places, but because of the tourniquet, "no bleeding was evident."
The penalty is $50,000. This is the hospital's fifth administrative penalty.
6. At Mercy Medical Center, Merced, Merced County, a 2.5-month old infant's hands endured third degree burns, ultimately requiring skin grafts, because nursing staff failed to follow guidelines in starting an IV catheter.
The infant had been brought to the emergency department by her parents for treatment of 10-day diarrhea and vomiting.
When nursing staff were unsuccessful with multiple attempts to start an IV for fluids, the nurse supervisor used a "vaginal light, without its attached speculum cover, in order to illuminate the veins in the infant's hand," which was not the manufacturer's intended purpose.
The manufacturer's instructions say "Warning: Lamp is harmful to skin if touched… Lamp is hot and can cause burn if used outside of the vaginal specula."
Additionally, the nursing staff was faulted for multiple attempts to start an IV, when hospital policy limits each staff member to two attempts.
The penalty is $50,000. This is the hospital's first administrative penalty.
7. At Mission Hospital Regional Medical Center, Mission Viejo, Orange County, a patient admitted with an internal jugular catheter suffered cardiac arrest and respiratory failure and required intubation when a nurse not competent to remove the catheter did so improperly.
The nurse, who was from a contract agency and was not on the hospital's staff, removed the catheter while the patient was sitting upright in a chair instead of in a supine position, which is necessary to prevent an air embolism, according to a state report. The nurse reported that the patient "was in a hurry to go home, so she had pulled the internal jugular catheter out while (the patient) was sitting upright in a chair."
The penalty is $100,000. This is the hospital's seventh administrative penalty.
8. At Santa Clara Valley Medical Center, San Jose, Santa Clara County, two patients received 16.6 times more than the intended dose of the chemotherapy drug methotrexate when a pharmacy technician failed to dilute them with normal saline, as the physician ordered, and the pharmacist failed to catch it.
One of the patients was observed with "twitching" movements in hands and legs, became drowsy, and required transfer to the intensive care unit. Eventually the symptoms resolved and the patient was discharged home to hospice care.
The other patient developed seizures and "generalized body jerky movement with a cardiac arrest, and also had to be transferred to the intensive care unit for intubation.
The penalty is $100,000. This is the hospital's fourth administrative penalty.
9. At Sharp Memorial Hospital, San Diego, San Diego County surgeons removed a 53-year-old man's left kidney instead of his cancerous right one. As a result, he must undergo life-long dialysis.
"The surgical team failed to have any of the relevant images of the kidneys available and displayed during any part of the surgical procedure," the state report said.
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.
See Also:
Medical Errors at 10 CA Hospitals Draw Fines of $625K