CDPH Fines 10 Hospitals $700,000

The California Department of Public Health announced on Wednesday it had fined 10 hospitals a total of $700,000 for errors that placed patients in immediate jeopardy of losing their lives. Patients died in seven of the incidents, including one where a retained surgical sponge was found to be at fault.

The penalties and fines include:

• UC San Diego Medical Center was fined $100,000 for a 2013 incident where a 58-year-old patient -- identified in media reports as Thomas Vera -- left the hospital premises and was found dead four days later in a canyon near the hospital’s parking structure. A panic button that was supposed to be available at the nursing station closest to the patient’s room was not installed. It was the hospital’s sixth penalty.

• Beverly Hospital in Montebello was fined $50,000 for a 2012 incident where an inexperienced nurse tried to insert a nasogastric tube five times without success. This led to excessive nose bleeding in the patient, who was taken a prescription anti-coagulant. He eventually had surgery to fix his injuries. This was the hospital’s first ever penalty.

• John F. Kennedy Memorial Hospital in Indio was fined $100,000 for a 2011 incident where it permitted a patient suffering from liver failure to be transferred to Riverside County Regional Medical Center in a private automobile, which broke down and required intervention to complete the transfer. The hospital agreed to revise its discharge policy. It was the facility’s sixth penalty. 

• Kaiser Foundation Hospital in Woodland Hills was fined $50,000 for a 2013 incident in which a 66-year-old surgical patient was given 19 doses of narcotics in a six-hour period, including five doses of the potentially deadly anesthetic fentanyl. This was the result of a family member bumping up prescribed dosages throuah a self-administering analgesic device for the patient, and dosing then even when they were asleep -- an incident that would not have occurred has the device been properly monitored by the hospital. This led the patient to stop breathing and their death about 10 days later. It was the hospital’s first fine.

• Loma Linda University Medical Center was fined $50,000 for a 2011 incident where a resident physician misread an x-ray, leading to the insertion of a feeding tube into the bottom of the patient’s right lung rather than their stomach. This led to the patient’s death. The hospital agreed to tighter supervision of its residents. It was the hospital’s third penalty.

• Mark Twain Medical Center in San Andreas was fined $50,000 for a 2013 incident where a towel was left inside a 78-year-old patient who underwent colon and hernia surgery. The towel compressed an artery, caused blood clots and led to his death. It was the hospital’s second penalty.

• Palomar Medical Center in Escondido was fined $50,000 for a 2013 incident where a 68-year-old stomach cancer patient fell out of bed, leading to a skull fracture, brain bleeding and his eventual death. An alarm indicated he would be getting out of bed had been turned off after a night of restless behavior on his part. This is the hospital’s first ever fine.

• Rideout Memorial Hospital in Marysville was fined $50,000 for a 2012 incident in which a patient was given 10 times their prescribed dosage of methadone due to a transcription error. Narcan was prescribed to reverse the overdose, but it was not administered. The patient died. Rideout management agreed to provide the nursing staff with additional training. It was the hospital’s first fine.
• Southwest Healthcare System in Murrieta was fined $100,000 for a 2011 incident where a 47-year-old patient with a history of pulmonary disease, diabetes and hypertension who was supposed to be admitted to the intensive care unit was kept in the emergency department and did not receive several medications required to stabilize her condition. She died as a result. This is the 13th penalty for Southwest, the most of any hospital in California.

• UCSF Medical Center in San Francisco was fined $100,000 for a 2011 incident where a patient was administered a chicken pox vaccine, despite a clinical contraindication against the patient receiving such a vaccine due to their contraction of common variable immune deficiency. The patient’s reaction to the vaccine led to multiple eye surgeries, and eventual loss of vision in their right eye and an inflamed retina in their left eye. Hospital officials agreed to improve its vaccine administrative policy. This was the ninth penalty for the hospital. 

A CDPH spokesperson did not immediately respond to a request seeking comment.

Based on prior data, the department has fined 174 hospitals a total of $15.7 million.