13 Hospitals Fined for Immediate Jeopardy Violations in CA

Cheryl Clark, for HealthLeaders Media , June 4, 2012

7. At Southwest Healthcare System, Murrieta, Riverside County, the facility failed to ensure that labor and delivery nurses provided emergency measures to sustain life of a fetus.

According to patient records, facility employees neglected to notify the physician that irregular fetal heart rate or beats per minute were being detected in the fetus or that personnel were having difficulty ascertaining them.

The fetus was delivered "with no respiratory effort, no heart rate, pale colour, no muscle tone noted. Resuscitation efforts started 0300. Code White Called." 

"The inability of the nurse to obtain and recognize an abnormal FHR rate pattern, a sign of fetal distress, resulted in a delay with notifying Patient A's physician, and a failure to provide emergency measures, which contributed to the death of Patient B, a full term, viable infant."

A bit more than a half an hour later, the physician ceased resuscitation.

The incident was Southwest's eighth penalty and resulted in a $100,000 fine. 

8. At the University of California San Diego Medical Center, San Diego County, a patient with chronic obstructive pulmonary disease and inadequate ventilation due to obesity was treated for a burn on the roof of her mouth and then discharged from the ED.

But she refused to leave saying she "could not breathe." She was nevertheless escorted out of the hospital by security, who along with an ED charge nurse and ED technician, tried to put her in a cab.

When she "put up a fight" the ED charge nurse "decided to take Patient 1 out of the cab. Patient 1 was then carried upside down toward a bench and placed prone (lying with the front or face downward) on the sidewalk in front of the bench."

The ED tech stated "this was not the best position for Patient 1 to be in given her anatomy" but the patient was "prone for a couple of minutes." A case manager arrived about five minutes later "and suggested that they turn Patient 1 over. "When they did Patient 1's lips were observed to be purple" and it was established she was not breathing.

She was resuscitated, intubated, and during her 28-day stay, part of it in the ICU, she required insertion of a tracheostomy.

UCSD "failed to provide considerate and respectful care to a patient who was treated in the ED. As a result, Patient 1 suffered a cardio-respiratory arrest during the discharge process from the ED."

The incident was UC San Diego's fourth penalty and resulted in a $75,000 fine. 

9. At Kaiser Foundation Hospital, San Diego County, the surgical team neglected to do a complete count of towels used for a patient.

"As a result, a blue towel was let undetected in Patient A's abdominal cavity for a period of 16 months. Patient A required a second surgery...for removal of the retained blue towel."  The 12-inch by 24-inch towel was ultimately discovered after the patient was readmitted with an abdominal mass that was detected by a CT scan.

The incident was Kaiser San Diego's first penalty and resulted in a $50,000 fine. 

10. At San Joaquin General Hospital, French Camp, in San Joaquin County, staff neglected to appropriately prevent a patient brought to the ED with complaints of falling at home and being too weak to get up off the floor for 36 hours. 

While in the hospital, the patient tried to get out of bed and fell, suffering a subdural hematoma and died thereafter due to cardiopulmonary arrest.

One entry in the medical record read "Found pt on floor after hearing loud crash. Attempted to get up to bedside commode without using call light. Bilateral heel protectors on, no skid proof socks."

The incident was San Joaquin Hospital's first penalty and resulted in a $25,000 fine. 

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