State fines 7 hospitals in region
The California Department of Public Health on Wednesday issued $25,000 penalties against 13 hospitals -- including seven in Los Angeles and Orange counties -- for serious violations that, in some cases, led to patient deaths.
Each violation comes with a $25,000 fine, part of an ongoing effort to hold hospitals more accountable for placing patients at risk of death or serious injury.
The disclosures come as a result of a state law that took effect in 2007 requiring hospitals to inform health regulators of all substantial injuries to their patients.
UC Irvine Medical Center was the only facility to get two penalties -- $50,000 in fines.
In one case, a UCI patient reported that she had been “inappropriately touched ‘vaginally’ ” by a male nursing assistant last September. State investigators found that it took the hospital three days to place the man on leave. “Other staff members felt he was a good employee,” according to a state investigation report, which noted that he had no history of complaints.
Hospital spokesman John Murray said the employee is no longer working at the hospital and the matter was turned over to the Orange County district attorney’s office for review.
In the second UCI case, a patient fell when reaching for the sink on the way to a bathroom last June. The fall caused bleeding in the brain, and the patient later died. At the time of the fall, the nurse assigned to the patient had left the area without informing colleagues. The hospital has since implemented a fall prevention program and teaching plan, provided high-risk patients with nonskid red socks and made bedside equipment available, including walkers.
“We are committed to redoubling our efforts to ensure the safety of each and every patient in our care,” said Terry A. Belmont, UCI Medical Center’s chief executive.
Other incidents that resulted in fines include:
* At St. Jude Medical Center in Fullerton, a surgeon left inside the patient a 10-by-10-inch plastic drape while performing a hysterectomy last July. The surgeon immediately realized his mistake and quickly brought the patient back in for a second surgery. The hospital performed a “root-cause analysis to make sure what had happened never happens again,” said Dr. Michael Marino, the hospital’s chief medical officer.
* At Whittier Hospital Medical Center, doctors began performing the wrong surgical procedure on a 63-year-old colon cancer patient last October. A nurse failed to check the woman’s wristband and wheeled her into the wrong operating room. Instead of the surgery planned for her -- implantation of a device that allows frequent blood withdrawals -- doctors began a pelvic exam and scraped the vaginal cuff for biopsies. Doctors did not realize they had the wrong patient until they discovered she had no uterus and ended the procedure. The hospital has “corrected the problems that led to this unfortunate incident,” hospital spokeswoman Frieda Wenzara said.
* An inexperienced nurse at Brotman Medical Center in Culver City administered a pain medication intravenously that should have been injected. The patient suffered a brain injury because of a lack of oxygen, fell into a coma and was placed on a ventilator. State investigators found that seven weeks after the first incident last July, the hospital violated its own policy by failing to mark all syringes filled with the same painkiller, hydromorphone, with a pink high-alert sticker. The hospital regrets the incidents and has revised its protocols, said Greg Schwarz, a Brotman vice president.
* At Harbor-UCLA Medical Center, medical staff left a sponge in a patient’s abdomen during surgery on Sept. 15, 2007. Nearly a year later, a hospital scan revealed the sponge surrounded by a cyst. Hospital spokeswoman Julie Rees said the hospital has taken corrective action by revising its policy on counting surgical sponges.
* At St. Francis Medical Center in Lynwood, medical staff gave a patient too much potassium to correct low electrolyte levels, triggering a fatal heart attack. After the patient was given the drug, medical staff did not measure the patient’s potassium levels for about one day, when they were critically high. State officials conducting a probe of the facility two months later found that the hospital had not enacted a new policy to monitor patients receiving potassium. During that inspection, they found that a patient had received potassium but was discharged without the hospital ever checking to see if the patient’s potassium level or heart rate was stable.
St. Francis will not appeal the fine. “We wanted to learn and improve from the experience,” said Trish Baseman, a vice president at St. Francis.
* At Hollywood Presbyterian Medical Center, nurses on Oct. 28 gave a patient blood intended for another person, causing the patient to die. The hospital issued a statement expressing its deep regret.