Seton Medical Center Fined $100,000

The skilled nursing facility at Seton Medical Center in Daly City has been fined $100,000 by the California Department of Public Health for a November 2014 incident that led to the suffocation of a patient.

The patient, a female with a history of pneumonia and profound swallowing problems, had had a permanent tracheostomy not long after she was admitted in January 2014. She was outfitted with a Passy-Muir valve, enabling her to speak for a few hours each day.

On the evening of Nov. 15 last year, a staff member removed the valve but apparently forgot to deinflate the tracheostomy cuff that kept the valve in place. As a result, the patient’s oxygen supply was cut off for at least seven minutes before she was found without a pulse and unresponsive. 

Because the patient was not wearing a band indicating whether or not a do-not-resuscitate order was in place -- a practice that did not take place in Seton’s nursing care unit -- life-saving measures were delayed by another 12 minutes, records show.

Seton, which is operated by the Daughters of Charity Health hospital system, agreed to put additional safeguards into place. They included additional training of staff and the potential use of Passy-Muir valves that do not require inflatable cuffs.

The fine, which was accompanied by a AA citation, is the stiffest that can be levied by the CDPH. The citation was not counted as an administrative penalty against the acute care portion of Seton Medical Center.