The violations, which resulted in the death of more than one patient, stem from poor nurse training, poor security practices, supervisory lapses, staff notification delays, and in one case, an inappropriate discharge instruction.
Because of serious medical mistakes at 10 California hospitals, eight patients died, an adolescent lost vision, and a tenth patient sustained severe bleeding from the nose due to medical errors, according to the California Department of Public Health.
The CDPH announced the latest round of penalties, totaling $700,000, Wednesday. It said they are the result of "facilities' noncompliance with licensing requirements" that caused, or were likely to cause serious injury or death to patients.
The violations stem from poor nurse training, lack of security, and an inappropriate discharge instruction.
The latest round of violations brings to about $17 million the aggregated fines issued since 2007 when the penalties went into effect by state law.
Violations that occurred before 2009 carry a fine of $25,000. Beginning Jan. 1, 2009, hospitals were issued penalties of $50,000 for the first violation, $75,000 for the second, and $100,000 for the third or subsequent violations.
As of April 1, 2014, the fines were raised to $75,000 for the first penalty, $100,000 for the second, and up to $125,000 for the third or subsequent violations.
CDPH officials say they have issued 341 immediate jeopardy penalties to date, with $16.4 million in fines, and has collected $13.4 million of that so far. Most of the remaining is under appeal. Of the money collected, $5.6 million has been spent on quality improvement programs.
1. Beverly Hospital, Montebello
Penalty: $50,000
The hospital's failure to properly ascertain competency for nasogastric tube insertion resulted in a nurse failing five times to insert the tube in a patient, causing profuse bleeding through the nose, state documents say.
The patient, coughing up blood, required transfer to the hospital's surgical care unit.
Proper procedure was that after two or three unsuccessful attempts, "a licensed nurse should have informed the charge nurse and notify the physician," but there was no documentation that that was done.
Records showed that the nurse's nasogastric competency, and another employee involved in the patient's care, were rated as a "1," defined as minimal experience, need review and supervision."
This is the hospital's first penalty.
2. John F. Kennedy Memorial Hospital, Indio
Penalty: $100,000
A woman with jaundice and liver failure was discharged with instructions to go to a facility 82 miles away by private automobile, which placed the patient "at risk for increased health deterioration, harm, and death."
The patient's car broke down en route.
The ambulance record said the patient, who was being driven to the second facility by her son, said she had been "released from hospital…due to no insurance and was told to follow up at Facility B and given directions to Facility B to go… via private vehicle despite patient weakness and low blood pressure. Family states they were driving patient to Facility B when vehicle broke down and … was unable to continue and called 911."
She arrived jaundiced and in septic shock. The episode resulted in her death that day.
This is the hospital's sixth penalty.
3. Kaiser Foundation Hospital Woodland Hills
Penalty: $50,000
A 66-year-old woman died after the hospital failed to limit access to a patient-controlled pain medication (PCA) device, resulting in an "unauthorized family member administering a narcotic medication to the patient," the report says.
According to state documents, during and after the patient's surgery, "the patient received 19 doses of three types of narcotic mediations within a six-hour time period," two hours after which the patient was found unresponsive, not breathing, and in cardiac arrest. The patient's pulse was restored but she was unresponsive, and died 10 days later.
This is the hospital's first penalty.
4. Loma Linda University Medical Center, Loma Linda
Penalty: $50,000
Failure to properly supervise medical residents resulted in a resident misreading an X-ray showing an improper nasogastric feeding tube placement in a pneumonia patient's lung instead of where it should have been placed, in the patient's stomach.
This failure, "resulted in patient 1 receiving liquid nutrition into the lung," state documents say. The patient subsequently went into respiratory distress, was placed on a ventilator, and a rapid response team was summoned. Ultimately, however, the patient died.
This is the hospital's third penalty.
5. Mark Twain Medical Center, San Andreas
Penalty: $50,000
A 78-year-old man died from complications after surgeons failed to remove a blue, non-radiopaque towel. The towel was used against hospital policy, which specifies such items should all be white and radiopaque.
Blue towels are to be placed around surgical openings, according to state documents, and were not involved in usual counts.
When the patient didn't recover from surgery as expected, experienced nausea, vomiting, abdominal pain and fever, two CTs were ordered, but failed to find the towel. A third CT showed "an area that looked like a 'sponge from the ocean.' "
The patient was transferred to a different facility where another CT was performed, suggesting "a foreign body." According to state documents the Mark Twain radiologist said, "Why I didn't think it was a foreign body, I don't know."
A day after another surgery removed the towel, the patient was encouraged to get out of bed. "When he stood up, he collapsed and coded… the staff could not revive him."
This is the hospital's second penalty.
6. Palomar Medical Center, Escondido
Penalty: $50,000
The hospital's failure to implement policies for fall prevention, including activating a fall alarm system, resulted in a 68-year-old man with pneumonia and stomach cancer sustaining a skull fracture with bleeding in the brain, and a coma.
"Ultimately, life support was withdrawn and Patient 1 expired in the hospital two days after falling."
According to state documents, the hospital was using a call bell alert system to notify when the patient tried to get out of bed, which he had tried to do on numerous occasions due to his confusion and agitation.
The alarm system failed to work, however, because "staff acknowledged the alarm had been turned off."
This is the hospital's first penalty.
7. Rideout Memorial Hospital, Marysville
Penalty: $50,000
An 83-yearold woman with heart failure and diarrhea died after she was given 10 times the ordered dose of methadone for pain, as much as 20 mg of morphine about two hours later, and was not administered the antidote Narcan fast enough.
Additionally, hospital officials could not account for a missing 17.5 mg of morphine that was reportedly withdrawn for the patient's use.
This is the hospital's first penalty.
8. Southwest Healthcare, Murrieta
Penalty: $100,000
Numerous nursing and physician notification delays, some as long as nearly four hours, prevented essential medications administered to a 47-year-old woman in the emergency department, despite numerous vital sign alarms and tests showing the patient was in medical distress.
The patient died in the ED, hours after being admitted to the hospital's ICU, which did not have a bed for her.
Though the patient "complained of sternal chest pain with difficulty breathing, and breath sounds were noted to be diminished with expiratory wheezing" and reported chest pain as 9 on a 10-point scale, the patient was given Xanax, and the physician was not informed of the change.
According to state documents, the ED physician reported noticing "that she had agonal respirations," which prompted life support efforts and code blue. "There was no documented evidence" that many of the drugs she needed were given to her.
This is the hospital's thirteenth penalty.
9. UCSF Medical Center, San Francisco
Penalty: $100,000
An adolescent with immune deficiency disease who should not have been immunized against chicken pox developed severe eye complications requiring multiple surgeries after a physician in the hospital outpatient department mistakenly administered the vaccine.
The patient developed retinitis in the left eye and loss of vision in the right one, and an accelerated risk of developing glaucoma.
The hospital also failed to have appropriate policies and procedures in place to guard against such an adverse event.
This is the hospital's ninth penalty.
10. University of California, San Diego Medical Center, San Diego
Penalty: $100,000
Lapses in hospital security resulted in the death a patient under care for a brain hemorrhage, who was allowed to walk out of the hospital.
The patient had limited mental capacity, which required that he not be allowed to leave even against medical advice, He was found dead from dehydration and pneumonia in a deep canyon next to the hospital's parking structure.
"The hospital had no written process or procedure regarding how staff was to contact security" and no process to identify patients "who should not be independently ambulating around the hospital or leaving the building because of safety concerns, state documents say. A "panic button" was pressed repeatedly, but it was broken.
Also, security did not receive multiple pages after technician watching a video monitor notified the nursing station the patient had left the room.
"Patient 1 walked out of his room in a patient gown and non-skid socks. He had a cervical collar in place" and exited the hospital's front lobby.
This is the hospital's sixth penalty.