CDPH Issues 10 Penalties To Hospitals

The California Department of Public Health issued 10 administrative penalties to nine hospitals and fines totaling $775,000 last week for lapses in care or medical errors that either killed patients or placed their lives in danger.

Community Regional Medical Center in Fresno received its first two penalties, both for incidents that occurred in 2012 where physicians ordered physician assistants to perform tasks for which they were not properly trained. In one instance, a physician assistant improperly removed an epidural catheter, leading to a collection of blood near the patient's spinal cord and leading to their paralysis below the waist. In another incident, a cardiovascular surgeon ordered a physician assisrant to close the chest incision of a patient undergoing the repair of an aortic aneurysm and left the hospital premises. The patient began to bleed uncontrollably after the incision was closed, leading to a level of blood loss that required the patient to be placed on life support.

Community Regional Medical Center took corrective actions to address the specific incidents. A statement issued by the hospital said “it continually trains and searches for ways we can improve our patient care and safety."

The other penalties include:

• Alvarado Hospital Medical Center in San Diego was fined $50,000. A patient at high risk for falling admitted to the facility last year died due to a subdural hematoma. The hospital had no plan in place to mitigate their risk for falling. It is the hospital's first penalty.

• Antelope Valley Hospital Medical Center in Lancaster was fined $50,000. A 2010 surgery led to a retained surgical object – a shield used to protect vital organs during procedures with sharp instruments. A string meant to identify the presence of the instrument had been severed during surgery. It is the hospital's first penalty.

• Los Angeles County Harbor-UCLA Medical Center was fined $50,000. A patient underwent a knee replacement surgery in 2011 where the prolonged use of a tourniquet led to vascular damage, the eventual amputation of his limb, and eventually his death. It was the hospital's fifth penalty. 

• Mercy Medical Center in Merced was fined $50,000. An infant suffered a third-degree burn on her palm in 2012 when an unshielded light used for vaginal exams was used to seek a vein for an intravenous catheter. Skin grafts were required to repair the damage. This was the hospital's first penalty. 

• Mission Hospital Regional Medical Center in Mission Viejo was fined $100,000. In a 2011 incident, a nurse was ordered to remove a jugular catheter even though she lacked the proper training to do so. The removal led to the patient's cardiac arrest, respiratory failure and intubation. This was the hospital's seventh penalty.

• Santa Clara Valley Medical Center in San Jose was fined $100,000. In an incident that occurred last year, a pharmacist and pharmacist tech failed to follow physician orders to dilute the chemotherapy drug methotrexate being administered to a patient. It led to the patient receiving 16.6 times the recommended dose, resulting in cardiac seizures. This was the hospital's fourth penalty.

• Sharp Memorial Hospital in San Diego was fined $100,000. A 53-year-old male patient had his left kidney removed in a procedure in 2012, as opposed to right cancerous kidney. This was the hospital's fourth penalty. 

• St. Jude Medical Center in Fullerton was fined $100,000.  A patient died in 2010 from a fall, and it was determined the hospital was not following fall prevention policies. This was the hospital's sixth penalty.

Since the CDPH began penalizing hospitals for dangerous medical errors, it has issued 295 penalties and fines totaling $13.35 million. $10.1 million has been collected to date, and 95 cases have been appealed.