The California Department of Public Health (CDPH) announced this week that it had fined 10 hospitals a total of $700,000 for incidents, and like the list released last July, it included safety violations that resulted in serious injury and death.
Fines ranging from $50,000 to $100,000 were meted out to medical centers in seven counties for incidents including the improper administering of feeding tubes and surgical materials left behind in a patient.
Some of the cases are old—one dates back to 2010—but have only recently been closed.
Beverly Hospital in Montebello, Los Angeles County—A nurse failed five times (pdf) to insert a nasal feeding tube into a patient in 2013, who ended up in intensive care with a bleeding, torn up nose. Another nurse successfully inserted the tube later. A doctor was supposed to be called after the second or third fail, but there is no record one was consulted. The hospital was fined for not ensuring the nurse was properly trained. $50,000
John F. Kennedy Memorial Hospital in Indio, Riverside County—A jaundiced patient suffering from liver failure (pdf) was admitted to the hospital in 2011. She did not have health insurance. The hospital wanted to discharge her, but she was “weak, nauseated and started to vomit.” So they waited a while and then discharged her with instructions to get treatment elsewhere. The record of the ambulance carrier that transported her noted, “Today she was released from hospital (per patient) due to no insurance.” At the second facility, she suffered septic shock and acute respiratory failure, and died. That is not a “safe and patient-focused discharge” and is the “hospital’s sixth Immediate Jeopardy administrative penalty.” $100,000
Kaiser Foundation Hospital, Woodland Hills in Los Angeles—A 66-year-old patient (pdf) admitted in 2013 with extreme constipation was scheduled for immediate surgery. After surgery, a relative pressed the sleeping woman’s patient-controlled analgesia (PCA) button and gave her a couple extra doses of a powerful narcotic. She died. The hospital was dinged for not enforcing its policy of not letting friends and relatives administer drugs to patients. $50,000
Loma Linda University Medical Center in San Bernardino County—A resident doctor failed to note (pdf) on an X-ray in 2010 that a feeding tube was inserted into a patient’s lung instead of his stomach. The patient died and the hospital was fined for not properly supervising the resident. $50,000
Mark Twain Medical Center in San Andreas, Calaveras County—“The facility failed to ensure facility policy and procedure for surgical services, ‘Prevention of Retained Surgical Items Policy-Sponge Counts,’ were followed.” A 78-year-old man died after a blue surgical towel was left inside him (pdf) during surgery to remove part of his colon. $50,000
Palomar Medical Center in Escondido, San Diego County—A 68-year-old man was admitted to the hospital with stomach cancer, pneumonia and respiratory failure. He ranted and rambled incoherently and repeatedly tried to get out of bed. The patient was deemed a high risk to fall out of bed and was hooked up to an alarm system. But someone turned it off before he fell out of bed (pdf) and smashed his head, resulting ultimately in death. $50,000
Rideout Memorial Hospital in Marysville, Yuba County—Doctors used methadone to relieve the pain of an 83-year-old woman admitted with chronic kidney disease, cramping and pulmonary hypertension. It was noted that she had a signed do-not-resuscitate form. Methadone shouldn’t be administered to old, debilitated patients. Her dosage was inadvertently set at 10 times that prescribed (pdf). She also may have gotten an ill-advised megadose of morphine. She died. $50,000
Southwest Healthcare in Murrieta, Riverside County—A 47-year-old patient with a history of serious ailments arrived via ambulance complaining of weakness and leg pains in 2011. A whole bunch of drugs were prescribed but apparently not administered (pdf). Nurses said they were very busy. The patient died. It was the hospital’s 13th Immediate Jeopardy administrative penalty. $100,000
UCSF Medical Center in San Francisco—A young patient with a known immune deficiency was administered the varlcela (chicken pox) vaccine. Turned out he didn’t need the vaccine (pdf) and it was especially dangerous to people with his medical condition. His medical history indicated he shouldn’t get it. The vaccine caused him to get varlcela infection in both eyes. Multiple surgeries followed. He lost sight in one eye and suffered impairment in the other. $100,000
University of California, San Diego Medical Center—A man was admitted to the hospital in 2013 after falling down a flight of stairs. He fractured his back and cracked his skull. He was disoriented and considered a high fall risk. But he didn’t stick around (pdf). “Patient 1 walked out of his room in a patient gown and nonskid socks. He had a cervical collar in place and walked past two sets of elevators and down a corridor” to the main lobby before exiting the hospital. Video cameras recorded his flight, but no one reported seeing him. When nurses noticed he was gone, they pushed a panic button but, as it turned out, the button did not work. He was found dead at the bottom of a canyon next to the medical center’s parking structure. $100,000