California healthcare regulators have fined thirteen hospitals in the state for lapses in patient care that resulted in serious adverse events to patients.
The California Department of Public Health (CDPH) announced that it has assessed administrative penalties and fines totaling $825,000 against thirteen California hospitals whose failure to follow policies and procedures or failure to provide a standard of care caused, or was likely to cause, serious injury or death to patients.
In accordance with new legislation that went into effect on January 1, 2009, an administrative penalty carries a fine of $50,000 for the first violation, $75,000 for the second, and $100,000 for the third or subsequent violation. Prior to 2009, CDPH administrative penalties carried a fine of $25,000. CDPH did not count events prior to the new legislation when determining the fine amounts.
Hospitals receiving administrative penalties and fines include:
Chapman Medical Center in Orange, CA – A female patient filed a complaint alleging that the nurse caring for her during an emergency room visit sexually assaulted her after administering a narcotic painkiller. Fined $75,000. This is the hospital’s second administrative penalty.
Chinese Hospital in San Francisco, CA – CDPH investigation found that nurses failed to ensure they had properly inserted the nasogastric tube (NGT) for feeding. The patient later died due to complications of aspiration pneumonia because the nurses inserted the NGT into the left lung, instead of the stomach. Fined $50,000. This is the hospital’s first administrative penalty.
Community Regional Medical Center in Fresno, CA – A medication error caused a patient to receive 50 times the dosage of Heparin, a drug used to slow blood clotting, ordered by the physician. She suffered an intracranial bleed, a bleeding of the blood vessels in the brain. Fined $50,000. This is the hospital’s first administrative penalty.
Kaiser foundation Hospital – Oakland/Richmond in Oakland, CA – CDPH found that nursing staff failed to respond to cardiac paging system alarms, resulting in a patient suffering brain death and subsequent death. Fined $75,000. This is the hospital’s second administrative penalty.
Kaiser Foundation Hospital – San Diego, CA – Surgeons left a towel inside a patient’s abdomen, necessitating removal of the towel in a subsequent surgery 16 months later. Fined $50,000. This is the hospital’s first administrative penalty.
Kaiser Foundation Hospital – San Francisco in San Francisco, CA – After a traumatic cesarean section and a second surgery to remove blood clots, a patient required a third surgery in less than 24 hours to remove a sponge left inside her body. Fined $75,000. This is the hospital’s second administrative penalty.
Keck Hospital of USC in Los Angeles, CA – A tip from an electrosurgical pencil/cautery was left inside the body of a patient during a surgical procedure. Fined $75,000. This is the hospital’s third administrative penalty.
Mad River Community Hospital in Arcata, CA – A patient suffered nausea, vomiting, abdominal pain and required additional surgery to remove a sponge left inside the body during a surgical procedure. Fined $50,000. This is the hospital’s first administrative penalty.
Motion Picture & Television Hospital in Woodland Hills, CA – A patient required an additional surgery two months after knee surgery to remove a sponge left behind in the knee. Fined $50,000. This is the hospital’s first administrative penalty.
San Joaquin General Hospital in French Camp, CA – The nursing staff failed to properly assess a patient’s fall risk, resulting in the patient sustaining head injury and death from a fall. Fined $25,000. This is the hospital’s first administrative penalty.
Santa Clara Valley Medical Center in San Jose, CA – The investigation showed a nurse removed a ventilator dependent patient from a ventilator and had a technician, who was not qualified to transport such a patient without nursing assistance, move the patient to another unit. Staff resuscitated the patient, but he died five days later when family made the decision to discontinue life support. Fined $75,000. This is the hospital’s second administrative penalty.
Southwest Healthcare System in Murrieta, CA – A full-term baby died during delivery after a nurse failed to recognize an abnormal fetal heart pattern, a sign that a baby in the womb is in distress, and take appropriate action. Doctors finally delivered the baby via emergency caesarian section and hospital staff worked unsuccessfully to revive the baby for 45 minutes. The coroner found that the baby died due to placental abruption and also had four puncture wounds in his chest, likely caused by the fetal monitor. Fined $100,000. This is the hospital’s eighth administrative penalty.
University of California, San Diego Medical Center in San Diego, CA – CDPH found the hospital failed to provide “considerate and respectful care” to a patient in the emergency department. When the patient refused to leave because she felt unwell, staff and security escorted her outside to a waiting taxi. However, the patient refused to get in the taxi by intentionally going limp and hospital security carried her face down and placed her on the sidewalk, a dangerous position for an obese person because of the potential for respiratory compromise. A supervisor arrived several minutes later, turned the patient over, found her lips blue and began CPR. The patient’s care required a 28-day hospital stay and a tracheotomy. Fined $75,000. This is the hospital’s fourth administrative penalty.
Each of the hospitals submitted a plan of correction to prevent similar events in the future. The hospitals can appeal their administrative penalty by requesting a hearing within ten days of notifications.