California has issued its latest round of administrative penalties to 13 hospitals where patients have been subject to serious injury or death as a result of regulatory noncompliance.
Five patients died, a sixth sustained severe neurological damage, a seventh coded but was resuscitated, and an eighth endured a second surgery because of a retained surgical sponge, according to state documents detailing dangerous errors in eight California hospitals.
These incidents, all of which resulted from regulatory noncompliance, resulted in assessments of $475,000 in financial penalties against these hospitals under the state's "immediate jeopardy" law. The state issued fines totaling $295,000 to another five hospitals where harm came to patients receiving treatment for mental or behavioral health.
Each event cited by the state caused or was likely to cause death or serious injury. Documents with specific descriptions of the incidents and each hospital's accepted plan of correction may be viewed on the California Department of Public Health's website. To date, the state has fined 166 hospitals under the immediate jeopardy statute a total of $14,105,000, $10,897,626 of which has been collected. Hospitals are appealing 62 fines.
The latest round of administrative penalties are:
1. Bakersfield Memorial Hospital, Bakersfield, CA
County: Kern
Penalty: $50,000
A patient who was hooked to a telemetry unit died of cardiopulmonary failure after the unit's audible alarms that would have indicated a low battery "were turned off."
"Patient 1 was found at 12:08 AM unresponsive and a code was called. The leads and telemetry box were attached to the patient but they were not reading the cardiac rhythm because the battery was dead," the state investigation report said. A registered nurse interviewed by investigators was watching the screen for cardiac rhythms for patients, but "saw no red alarm (indicating a critical cardiac rhythm.). The screen was blank, like no patient was there."
This is the hospital's second administrative penalty.
2. Fountain Valley Regional Hospital and Medical Center, Fountain Valley
County: Orange
Penalty: $75,000
A patient under care in the cardiac catheterization lab died from head injuries due to a fall because staff were not "validated to be competent" to apply a pressure device that required the patient be turned side-to-side.
While the patient was turned to her right side for the application of the pressure device, on a table described as "narrow and slippery," her "head, shoulders and chest slipped down off the table. The upper body of the patient fell to the floor. The patient hit her head and sustained a subdural hematoma?[and] passed away two days later."
This is the hospital's fourth administrative penalty.
3. Garden Grove Hospital and Medical Center, Garden Grove
County: Orange
Penalty: $50,000
A patient died from an overdose of a powerful sedative after mishearing the physician's order and failing to read it back according to policy.
State documents report that a physician involved (MD 1) said "he noticed the patient's condition changed (respiratory rate and level of consciousness) after administration of Versed.
MD 1 said, 'I asked RN 1 how much Versed had been administered.' MD 1 elaborated, 'I was shocked when he told me 4 milligrams. I didn't order that.' The physician looked down, shook his head, and stated, 'If (RN 1) had read back the Versed order to me I would have stopped him?I said Versed 1 milligram or .5 milligrams."
This is the hospital's third administrative penalty.
4. Los Angeles Community Hospital, Los Angeles
County: Los Angeles
Penalty: $50,000
A patient received a dose of heparin 10 times higher than what was ordered because, according to state documents, "the pharmacist failed to transcribe the order correctly" for a heparin drip, a high-alert medication.
"Subsequently, the patient experienced bleeding from orifices around the surgical site, decreased blood pressure, and respiratory distress that eventually required resuscitation and mechanical ventilation support."
This is the hospital's second administrative penalty.
5. Mercy Medical Center, Merced
County: Merced County
Penalty: $75,000
Failure to do proper blood clotting tests and respond to them before and during a heparin drip resulted in an overdose that caused a patient death.
Though lab tests were done, they indicated clotting at greater than 400 seconds. "The lab considered the results erroneous and did not report them to the RN. Rather, the lab redrew the [blood]?Again the results were greater than 400 seconds?"
"In addition, nursing staff did not report to the doctor the abnormal signs and symptoms of Patient 1's reaction to the heparin treatment (bleeding at the groin incision site, low blood pressure, and lethargy) until two and a half hours after first observed. These failures resulted in a delay in Patient 1 receiving treatment for the heparin overdose, leading to a continued decline in condition. As a result, Patient 1 expired."
This is Mercy's second administrative penalty.
6. Regional Medical Center of San Jose, San Jose
County: Santa Clara County
Penalty: $50,000
A patient sustained severe neurological damage after a nurse inadvertently connected a cylinder of carbon dioxide gas to tubing for ventilation instead of oxygen.
"Failure of the patient to receive oxygen as ordered caused the patient to become hypoxic (without oxygen) which required emergency medical treatment for stabilization. The patient suffered significant medical complications, including neurological damage, as a result of the incident.
This is the hospital's first administrative penalty.
7. At Ronald Reagan UCLA Medical Center, Los Angeles
County: Los Angeles
Penalty: $75,000
An incorrect surgical object count resulted in a patient leaving the operating room with a retained surgical lap sponge, and having to undergo a second surgery days later to remove it.
Several days later, the patient received a CT of the abdomen and pelvis due to nausea, increased white blood cells and was to be evaluated for fluid collection. "The diagnostic report showed a 'lap marker' (the string to grab the sponge) adjacent to the right lobe of the liver with surrounding gas and fluid and that the collection measured 11x4 centimeters."
This is the hospital's second administrative penalty.
8. At St. Joseph Hospital, Orange
County: Orange
Penalty: $50,000
A patient undergoing a Cesarean section coded and required resuscitation because staff failed to alert a physician that her blood pressure had dropped and her heart rate had increased for four hours.
"After a change of shift in the post-operative recovery room, the oncoming RN was unaware of the patient's pre-operative laboratory results and did not review the patient's pre-operative vital signs?or any vital signs taken prior to the change of shift."
There was no further status documentation "until the hospital's Medical Emergency Team was called?the patient had a seizure, required ventilation and was transferred to the ICU where the patient had a cardiac arrest," according to state documents. "The patient's condition deteriorated and she passed away."
This is the hospital's third administrative penalty.
Harm to Psychiatric Patients
California also issued immediate jeopardy fines totaling $295,000 to five hospitals where patients who were undergoing care related to mental or behavioral health were harmed. Documents detailing these incidents can not be released according to confidentially provisions in state law. Those organizations and their fines:
- Aurora San Diego ? $75,000
- LAC/Harbor-UCLA Medical Center ? $75,000
- Memorial Hospital Los Banos ? $20,000
- Pacifica Hospital of the Valley ? $50,000
- University of California Irvine Medical Center ? $75,000
State officials released no other information on these incidents.