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13 Hospitals Fined for Immediate Jeopardy Violations in CA

 |  By cclark@healthleadersmedia.com  
   June 04, 2012

One patient died after a nasogastric feeding tube was inserted into his lung instead of his stomach in San Francisco, a tracheostomy patient died after being transported without a ventilator in San Jose, and a nurse's inability to recognize fetal distress resulted in the death of a full-term viable infant in Murrieta, the eighth such egregious event at that hospital in the last four years.

These are among 13 immediate jeopardy penalties totaling $825,000 levied against California hospitals Friday in the latest disciplinary actions in which acute care facilities caused or were likely to cause harm to patients, state officials said.

Of incidents that did not result in death, a morbidly obese woman who sought care in a San Diego ED and complained she "could not breathe" was not admitted to the hospital. Instead, she was escorted to a cab by personnel and instructed to go home. When she became combative, she was carried "upside down" to a bench and placed prone, suffering cardio-respiratory arrest. 

In a hospital in Orange, a patient was injected with narcotics and then sexually assaulted by a nurse, a criminal offense.

"In issuing these administrative penalties, our goal at the Department of Public Health is to improve the quality of healthcare in all California hospitals," Debby Rogers, deputy director of the Center for Health Care Quality, said in a news briefing.  She said that information on what led to these incidents "will be used to determine how the violations or deficiencies can be decreased or eliminated over time."

Several laws enacted since 2007 to make California's hospitals more accountable for safe care. They have resulted in 224 such penalties to 129 hospitals and $7.7 million in fines, Rogers said.  Several hospitals have received three or more penalties and one hospital, Southwest Medical Center in Murrieta, now has eight, the most of any California hospital.

The fines amount to $25,000 for incidents occurring prior to 2009. After 2009, the fine increases to $50,000 for the first violation, $75,000 for the second and $100,000 for a third or subsequent violation at the same facility. All fines announced Friday resulted in investigations of incidents that occurred between 2009 and 2011.

Rogers said the delay in imposing these penalties so long after the events and their investigations occurred was due to "a very robust review process with our legal and survey teams to make sure the penalty is appropriate, and for some of the penalties, it's a long process."

California health officials are currently working to increase the penalty amounts to a maximum of $125,000. The revisions also would allow regulators more flexibility to take into consideration the patient's physical and mental status, the probability and severity of the risk to the patient, actual financial harm, the facility's history of regulatory compliance, factors beyond the facility's control, the willfulness of the violation and the extent to which the facility detected the problem and took steps to correct it.

Rogers said that retained foreign objects continue to be the most common reason for immediate jeopardy penalties against hospitals, accounting for 26%. Those are followed by medication errors, 24%; patient safety issues, 17.8%; and patient care issues, 17.4%.

According to state documents, which can be found on the state website by county, these are some details of each incident:

1. At Kaiser Foundation Hospital in Oakland/Richmond, in Alameda County, a telemetry unit patient died after his cardiac monitor sent alarms to the nurse's paging device indicating rapid heart rates, and a notification of a low battery, "neither of which was responded to."

Eventually, the alarm changed to "replace battery," which means 'no monitoring is occurring and the battery should be replaced immediately.

By the time the "replace battery" notification was acted on, the patient "was found pulseless, unresponsive, and in cardiac arrest."

"Approximately six minutes passed between when the monitoring system could not analyze Patient A's cardiac rhythm and when RN2 called the emergency code to attempt resuscitation of the patient."

The incident was Kaiser Oakland's second penalty and resulted in a $75,000 fine. 

2. At Community Regional Medical Center, Fresno, in Fresno County, a nurse administered 50 times the physician's ordered amount of heparin to a patient, causing an intracranial bleed resulting in death.

According to the hospital's risk manager, "the IR nurse programmed the pump (equipment used to precisely administer IV medication) to administer 300 ml an hour instead of 300 units an hour." Also, the programming nurse had not programmed the pump to use guardrails, built in safety mechanisms that send alerts when safety parameters of high-risk medications like heparin aren't met.

The incident was Community Regional's first penalty and resulted in a $50,000 fine. 

3. At Mad River Community Hospital in Arcata, Humboldt County, a surgical team neglected to remove a laparotomy towel from a colon resection patient who had been discharged home, but who returned because of abdominal pain, nausea.

The state report said that hospital policy did not set forth that sponge, instrument, and sharp counts do not include dressings with which a patient may enter the operating room.

"The director of Surgical services said she saw an increased risk of error given the surgical team had worked all day and then were on call for the night of ... when the surgery started at 10:00 P.M."

The incident was Mad River's first penalty and resulted in a $50,000 fine. 

4. At Keck Hospital of USC, Los Angeles County, cardiothoracic surgeons failed to remove a tip from an electrosurgical pencil cautery used for a patient who had undergone an aortic valve repair.  The patient had to undergo a second surgical procedure under general anesthesia.

The incident was Keck's third penalty and resulted in a $75,000 fine. 

5. At Motion Picture & Television Hospital, Woodland Hills, Los Angeles County, surgeons forgot to remove a 10.18 cm by 10.18 cm Raytec sponge that had been used to pack the wound in the knee of a patient who had undergone an ACL reconstruction. 

California officials were alerted to the sponge retention by a "letter" saying that the patient had gone back to the surgeon two months later "with concerns of a lump in the knee area."

When the sponge was identified through imaging, the patient went to another hospital to have it removed. 

The incident was Motion Picture & Television Hospital's first penalty and resulted in a $50,000 fine. 

6. At Chapman Medical Center, Orange, in Orange County, the hospital failed to protect a patient from sexual misconduct and assault by a registered nurse who had injected her with narcotic and/or opiate pain killers and a muscle relaxant.

"A review of the police agency's investigative report by Officer Y, documenting RN 1 admitted to administering the aforementioned medications and kissing Patient A on the mouth using his tongue, fondled her breasts and he stated she touched his erect penis with her hand."

The patient was later asked if she voluntarily participated in the incident "and she stated, no, because she could not move her arms."

The nurse was immediately suspended and arrested by police.

The incident was Chapman's second penalty and resulted in a $75,000 fine. 

7. At Southwest Healthcare System, Murrieta, Riverside County, the facility failed to ensure that labor and delivery nurses provided emergency measures to sustain life of a fetus.

According to patient records, facility employees neglected to notify the physician that irregular fetal heart rate or beats per minute were being detected in the fetus or that personnel were having difficulty ascertaining them.

The fetus was delivered "with no respiratory effort, no heart rate, pale colour, no muscle tone noted. Resuscitation efforts started 0300. Code White Called." 

"The inability of the nurse to obtain and recognize an abnormal FHR rate pattern, a sign of fetal distress, resulted in a delay with notifying Patient A's physician, and a failure to provide emergency measures, which contributed to the death of Patient B, a full term, viable infant."

A bit more than a half an hour later, the physician ceased resuscitation.

The incident was Southwest's eighth penalty and resulted in a $100,000 fine. 

8. At the University of California San Diego Medical Center, San Diego County, a patient with chronic obstructive pulmonary disease and inadequate ventilation due to obesity was treated for a burn on the roof of her mouth and then discharged from the ED.

But she refused to leave saying she "could not breathe." She was nevertheless escorted out of the hospital by security, who along with an ED charge nurse and ED technician, tried to put her in a cab.

When she "put up a fight" the ED charge nurse "decided to take Patient 1 out of the cab. Patient 1 was then carried upside down toward a bench and placed prone (lying with the front or face downward) on the sidewalk in front of the bench."

The ED tech stated "this was not the best position for Patient 1 to be in given her anatomy" but the patient was "prone for a couple of minutes." A case manager arrived about five minutes later "and suggested that they turn Patient 1 over. "When they did Patient 1's lips were observed to be purple" and it was established she was not breathing.

She was resuscitated, intubated, and during her 28-day stay, part of it in the ICU, she required insertion of a tracheostomy.

UCSD "failed to provide considerate and respectful care to a patient who was treated in the ED. As a result, Patient 1 suffered a cardio-respiratory arrest during the discharge process from the ED."

The incident was UC San Diego's fourth penalty and resulted in a $75,000 fine. 

9. At Kaiser Foundation Hospital, San Diego County, the surgical team neglected to do a complete count of towels used for a patient.

"As a result, a blue towel was let undetected in Patient A's abdominal cavity for a period of 16 months. Patient A required a second surgery...for removal of the retained blue towel."  The 12-inch by 24-inch towel was ultimately discovered after the patient was readmitted with an abdominal mass that was detected by a CT scan.

The incident was Kaiser San Diego's first penalty and resulted in a $50,000 fine. 

10. At San Joaquin General Hospital, French Camp, in San Joaquin County, staff neglected to appropriately prevent a patient brought to the ED with complaints of falling at home and being too weak to get up off the floor for 36 hours. 

While in the hospital, the patient tried to get out of bed and fell, suffering a subdural hematoma and died thereafter due to cardiopulmonary arrest.

One entry in the medical record read "Found pt on floor after hearing loud crash. Attempted to get up to bedside commode without using call light. Bilateral heel protectors on, no skid proof socks."

The incident was San Joaquin Hospital's first penalty and resulted in a $25,000 fine. 

11. At Santa Clara Valley Medical Center, San Jose, Santa Clara County, a patient with a tracheostomy who also was on a ventilator was transferred from the ED to the transitional care neurological unit for acute coronary insufficiency, but without the ventilator.

According to the state report, when transferring a ventilated patient, the nurse, respiratory therapist and a certified nurse assistant all are part of the transfer team. The respiratory therapist "bags" the patient, the nurse watches the monitors and the nursing assistant assists with the bed transport.

But these arrangements were not made because another nurse informed a hospital transporter, an employee who transfers patients, that "it was 'OK' to transport the patient and not to worry about the transport."

"What should I do if something happens during transport?" the hospital transporter asked. The nurse responded, "Nothing will happen."

When the respiratory therapist who was supposed to be part of the transport team discovered the patient had been transferred without him, he told state investigators, "I was shocked no one told me the patient was being transferred."

Between six to 10 minutes after leaving the ER with the patient, the hospital transporter entered the room "touched patient 1s arm and felt the patient's skin was cold...his eyes were rolled up, and his lips were blue" and he had no pulse or cardiac electrical activity.

A Code Blue was called, CPR initiated and the patient was resuscitated, but the patient died five days later after the family made the decision to discontinue life support.

The incident was Santa Clara Valley's second penalty and resulted in a $75,000 fine. 

12. At Kaiser Foundation Hospital, San Francisco County, surgeons neglected to remove a laparotomy sponge in a patient who required an emergency C-section, a laparotomy due to excessive bleeding.

"It was a crazy case that day," a surgical technician told state investigators. "(The patient) was bleeding and they were trying to keep the laps in order." The tech remembered doing the count but "did not go into" the counter bags. "In hind sight, she remembered that there was a sponge 'out in the field' on the patient's abdomen and also one sponge on the floor."

"When she asked Circulating Nurse 1 if the sponge on the floor was accounted for, Circulating Nurse 1 told her 'it's OK.'  The conclusion of the facility's investigation was that circulating nurse 1 double-counted the sponge either on the patient's abdomen or the one on the floor."

"Under an already compromised condition, Patient-1 had to undergo a third surgery to remove the retained sponge from the second surgery."

The incident was Kaiser San Francisco's second penalty and resulted in a $75,000 fine. 

13. At Chinese Hospital, San Francisco County, a patient died after a nasogastric tube was placed in the left lung of a patient, who died the next day from aspiration pneumonia.

There was no documentation that the two nurses "informed the physician that the patient kept coughing and shaking the head during the NGT tube insertion, and they took several attempts to insert the nasogastric tube."

There was also no documentation of competency validation and/or in-service training for NGT insertion in the last 12 months" for the two nurses.

The incident was Chinese Hospital's first penalty and resulted in a $50,000 fine. 

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