Eight Hospitals Fined For Safety Issues

The California Department of Public Health (CDPH) has issued administrative penalties and fines totaling $483,650 to eight hospitals for incidents that jeopardized the lives of patients. Details about the incidents released by the CDPH last week indicated that they led to four patient deaths.

It is the first time since May 2015 that the CDPH has issued any penalties and fines to hospitals over patient safety issues, and only the third time in the past year. Payers & Providers recently reported a 50% decline in such fines and penalties over the past couple of years and a steep dropoff since the earliest days of enforcement in 2007 and 2008.

Sources say the decline is attributable to CDPH staff shortages and turnover, although it appears  the agency is beefing up its presence in Southern California.

The most recent penalties and fines include:

• Community Regional Medical Center in Fresno was fined $86,625 for a 2014 incident in which a nearly two-square foot towel was left in the abdomen of a surgical patient. The towel went undetected despite indications that the materials inventory for the procedure was out of sync with what was used, and one of the supervising physicians declined to use a CT scan on the patient. The patient endured signifcant abdominal pain and lost more than 40 pounds before the sponge was located and removed about three months after the original surgery. The hospital conceded that it did not keep a precise count of surgical towels in the past. It instituted a new policy of counting such towels and either using using towels that will appear in imaging or can be accounted for electronically. It is the hospital's fourth administrative penalty. The previous penalties were issued in 2013 and 2012.

• The Kaiser Foundation Hospital in Fontana was fined $75,000 for a 2014 incident in which a patient placed on a high table for imaging fell on her head. The fall led to a brain hemorrhage and the patient died four days later. According to the incident report, the patient was attached to a “waffle” mattress when she was brought to the imaging table, which is not part of protocol. The hospital's nuclear imaging department underwent additional training in order ensure adherence to policy moving forward. It is the second penalty. It was previously penalized in 2010.

• The Kaiser Foundation Hospital in Santa Rosa was fined $50,000 for a 2010 incident in which a wound vacuum sponge remained in the left thigh of a patient being treated for a catastrophic skin infection. The sponge was not detected and removed until three weeks after its insertion. The hospital began counting such sponges as part of its surgical protocol. It was the facility's first penalty and fine.

• San Joaquin General Hospital in French Camp was fined $75,000 for a 2009 incident in which a patient admitted through the emergency room received a double dosage of thrombolytic medications due to a lack of communication from ER staff after the patient was admitted. She suffered a brain hemmorhage and died. The hospital reinforced its policies regarding interdepartmental communications regarding patient treatments. This was the hospital's second administrative penalty. It was previously cited in 2012.

• Sonoma Valley Hospital in Sonoma was fined $50,000 for a 2012 incident in which a patellar protector was left in a patient who underwent knee surgery. Surgical staff did not have a protocol in place for keeping track of such devices, even though a representative for the company that sold the hospital the device had informed staff that it could not be accounted for. It was initially thought to have been lost in the folds of the patient’s surgical gown. The hospital changed its protocols for keeping track of such devices in the future. It was the hospital's first penalty and fine.

• Twin Cities Hospital in Templeton was fined $50,000 for a 2013 incident in which a patient undergoing surgery for a mallet finger had her left pinkie finger operated on, rather than her left ring finger, requiring a second surgery. The incident was the result of an error in a prior pre-surgical report that misidentified the finger. The hospital revised its policies to avoid such surgical errors in the future. It is the hospital's first administrative penalty and fine.

• Ventura County Medical Center was fined $50,000 for a 2014 incident in which a psychiatric patient with suicidal ideation was admitted without being properly searched, per the hospital’s written policy. The patient was later found hanged with a cord that was brought into the facility in their clothing and died as a result. This was the hospital's third penalty. It was previously cited twice in 2011.

• Vibra Hospital in San Diego was fined $47,025 for a 2014 incident in which a registered nurse ignored an alarm on a patient's respirator. The patient suffered brain damage as a result and was moved into the intensive care unit and died 28 days later. It was the hospital's first administrative penalty.

Altogether, the CDPH has issued 194 administrative penalties against hospitals for jeopardizing patients since 2007, when the agency was authorized under law. Altogether, 106 patients have died in connection to the incidents. The fines have totaled $16.96 million. About half of the incidents – 94 – have been appealed or are currently under appeal.

Meanwhile, it appears that Los Angeles County is filling as many as 70 new positions for hospital inspections as a result of extra money in the state's 2015-16 budget, several sources say. 

The inspectors would work in conjunction with the Los Angeles County Department of Public Health after their training is complete, which could take up to six months, sources say.

Officials with both the state and L.A. County DPH did not immediately respond to a request seeking comment.