13 Hospitals Fined $745,000 By CDPH

The California Department of Public Health has issued administrative penalties to 13 hospitals and issued fines totaling $745,000 for errors that placed patients in immediate danger. 

The incidents, which occurred between 2010 and last year, led to the deaths of at least five patients, according to the records publicly disclosed by the agency late last week.

However, the CDPH did not disclose specific details of penalties for five hospitals that included fines totaling $295,000. 

The CDPH cited the state’s Welfare and Institutions Code for not releasing details. The specific portion of the code cited has to do with protecting the confidentiality of mental health patients, although patient names are typically redacted from such reports before they are released. A CDPH spokesperson was unable to provide more specifics Thursday.

However, the CDPH will sometimes withhold documents regarding penalties and fines when a hospital files an appeal, and has been known to even withdraw previously public documents from scrutiny if an appeal is successful.

Officials with the hospitals either declined to comment or did not respond to requests seeking comment Wednesday and Thursday.

The undisclosed penalties include:

Los Angeles County Harbor/UCLA Medical Center was fined $75,000 after an on-site visit that took place in 2011. It was the hospital’s sixth administrative penalty.

UC Irvine Medical Center received its fifth administrative penalty and a $75,000 fine. 

Aurora Behaviorial Healthcare’s San Diego facility received a $75,000 fine and its second administrative penalty.

Pacifica Hospital of the Valley in the San Fernando Valley received a $50,000 fine for its first administrative penalty.

Memorial Hospital of Los Banos received its first administrative penalty and a $20,000 fine.

The publicly disclosed cases include:

• Fountain Valley Regional Medical Center

A nurse failed to properly assess a patient undergoing a cardiac catheterization. Properly trained staff were not made available during the procedure, which included the use of a high-pressure device to control bleeding. As a result, the patient partially fell off the table during the procedure, struck her head and suffered a hematoma that led to her death. This was the hospital's fourth administrative penalty, and led to a $75,000 fine.

• Garden Grove Hospital and Medical Center

A nurse failed to read back verbal orders from a physician regarding anesthetic applied to a pneumonia patient for a bedside endoscopy. The patient received an incorrect amount of drugs and died nine days later. This is the hospital's third administrative penalty. It resulted in a $50,000 fine.

• St. Joseph Hospital, Orange

A patient who underwent a C-section in 2012 was not properly monitored by nursing staff while in the recovery room, leading to their missing signs of an elevated heartbeat and low blood pressure. The patient had a seizure and died. This was the hospital's third administrative penalty. It resulted in a $50,000 fine.

• Los Angeles Community Hospital

A patient undergoing surgery for a gangrenous foot in 2013 received a dose of the blood thinner heparin 10 times above the safe dose to a pharmacist's transcribing error. The patient required another drug regimen to reverse excess bleeding and needed to be placed on a ventilator. This was the hospital's second administrative penalty. It resulted in a $50,000 fine.

• Mercy Medical Center, Merced

A patient undergoing a cardiac catheterization procedure expired due to a poor reaction from heparin. The hospital's guidelines were not followed in the administration of the drug. This was the hospital's second administrative penalty. It resulted in a $50,000 fine.

• Regional Medical Center of San Jose

Due to a nurse's error, a 68-year-old patient undergoing an exploratory abdominal surgery in 2012 received carbon dioxide instead of oxygen while under general anesthesia. The patient suffered hypoxia and brain damage as a result. 

This was the hospital's first administrative penalty. It resulted in a $50,000 fine.

• Ronald Reagan UCLA Medical Center

A patient undergoing a laparotomy in 2011 had a sponge left next to their liver due to an incorrect count by the surgeon and surgical nurse. It required a second surgery to remove. This was the hospital's second administrative penalty. It resulted in retraining of staff. The fine was $75,000.

• Bakersfield Memorial Hospital

The hospital’s medical staff was cited for a failure to answer cardiac rhythm alarms, and allowed the batteries to die in one monitoring a 63-year-old female patient with a history of atrial fibrillation. She died as a result. It is the hospital's second administrative penalty, and resulted in a $50,000 fine.

Altogether, the CDPH has issued 303 penalties and fines totaling $14.1 million. It has collected $10.9 million in fines.

Sixty-two of the penalties are currently under appeal and may eventually be heard by an administrative law judge, according to CDPH officials, although legal experts say the process can drag on for years. That’s primarily due to a shortage of judges able to hear such cases, leading to a huge backlog of cases.

According to the few legal documents obtained by Payers & Providers about such cases, the appeals tend to be based on the legal concept of laches – that too much time has passed for a civil penalty to be levied. An unknown number of penalties have been successfulyl fought and removed or reduced.