The patient was then minimally responsive following the fall, and was placed in an extended care facility on hospice, where he died four days later.
State documents said the patient had fall precautions in place and a tab alarm, but had removed them. A sitter to monitor the patient had been reassigned. Asked why a sitter was not used for the patient, "according to RN 2, the supervisor told her there were a hundred other things to do before utilizing a sitter."
Pomerado received a $75,000 fine, its second administrative penalty.
3. At Sharp Memorial Hospital, also in San Diego County, a heart attack patient died of an overdose of the medication Milrinone.
According to state documents, the staff member who administered the medication "had not demonstrated all the standards of competency for the Intensive Care Unit." The staff member had failed to properly program the Alans Medley Infusion Pump with the name and dose of the drug to activate its guardrail safety feature.
The staff member was "new to the hospital" and was undergoing clinical training with a preceptor in the medical intensive care unit.
According to the pump's tracker, "the entire dose of 100cc of Milrinone was administered within approximately 7 minutes" or 3.6 times the prescribed dose.
Sharp received a $25,000 fine for the 2008 incident.
4. At Contra Costa Medical Center in Contra Costa County, a 25-year-old woman who had just given birth received fentanyl and bupivicaine for pain intravenously instead of pitocin, (oxytocin-medication given immediately after delivery to control uterine bleeding), which prompted a Code Blue, state documents said.